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Full text of "Choosing a Medigap policy : ... guide to health insurance for people with Medicare"


2003 Guide To Health 
Insurance For People 
With Medicare 



For People in the Original 
Medicare Plan 



This Guide has easy steps to help 
you buy Medicare Supplement 
Insurance. 



Welcome to the 2003 Guide To Health Insurance 
For People With Medicare: Choosing A Medigap 
Policy 

How This Guide Can Help You 

This Guide is about "Medicare Supplement Insurance," also called "Medigap 
Policies." A Medigap policy is a health insurance policy sold by private insurance 
companies to help you pay some of the medical costs the Original Medicare Plan 
(fee-for-service) doesn't cover. Choosing a Medigap policy is a very important 
decision. 

This Guide provides you with valuable information and helps you understand: 

• What Medigap policies are, 

• How Medigap policies can help you, 

• What to do before you buy a Medigap policy, and 

• How to choose the best Medigap policy for you. 

Only you can decide if you need a Medigap policy with the Original Medicare 
Plan. This Guide can help you! 

Remember, there are many things to think about before you make a decision. 
There are other kinds of health coverage, besides a Medigap policy, that may pay 
for some of your health care costs not covered by Medicare (see page 58). 

You don't need a Medigap policy if you are in a Medicare + Choice Plan. 



The 2003 Guide To Health Insurance For People With Medicare: Choosing A Medigap Policy is 
not a legal document. The official Medicare program provisions are contained in the relevant 
laws, regulations, and rulings. 

The information in this Guide was correct when it was printed. Changes may occur after 
printing. For the most up-to-date version, look at www.medicare.gov on the web. Select 
"Publications." Or, call 1-800-MEDICARE (1-800-633-4227). A Customer Service 
Representative can tell you if the information has been updated. TTY users should call 

1-877-486-2048. 



Table of Contents 



^ Section 1: A Quick Look At Medicare 3-8 

Medicare Health Plan Choices 4 

Medicare Part A 5 

Medicare Part B 5-8 

Section 2: Medigap Policy Basics 9-32 

Learning About Medigap (What It Is, What's Covered) 10-14 

Your Medigap Plan Choices 15 

Information on Costs 16-17 

Best Time To Buy A Medigap Policy 18-20 

Steps To Buying A Medigap Policy 20-31 

Section 3: More Detailed Medigap Policy Information .33-56 

Ways of Pricing Medigap Policies 34-35 

Pre-existing Conditions 36 

Creditable Coverage 37 

Medigap Policies For People Under Age 65 38-40 

Information on Medicare Health Plans and Medigap Policies 40 

Medigap Rights and Protections (Guaranteed Issue Rights) 41-48 

Learning More About Medigap Coverage, Policies, and Companies ....49-55 

Section 4: Other Ways To Pay Health Care Costs 57-66 

Other Kinds of Insurance and Ways To Pay Health Care Costs 58-66 

Section 5: Coverage Charts 67-76 

Medicare Part A Coverage Chart 69 

Medicare Part B Coverage Charts 70-72 

Information for Residents of Massachusetts, Minnesota, and 
Wisconsin 73-75 

Section 6: For More Information 77-80 

Important telephone numbers for each state 79-80 

Section 7: Words To Know 81-86 

Where words in purple are defined 82-85 

Section 8: Index 87-89 

An alphabetical list of what is in this Guide 88-89 



Notes 



Section 1: 

A Quick Look At 

Medicare 




"We weren't sure what Medicare covered 
until we read over this section." 



Section 1: A Quick Look At Medicare 



Medicare has two parts: 

• Part A Hospital Insurance, see page 5. Most people don't have to pay for Part A. 

• Part B Medical Insurance, see pages 5-8. Most people pay monthly for Part B. 

Medicare Health Plan Choices 

Depending on where you live, you may be able to get your health care coverage in 
several ways. Medicare offers the following types of Medicare health plans: 



Medigap 
policies only 
help pay 
health care 
costs if you 
are in the 
Original 
Medicare 
Plan. 



The Original Medicare Plan - The Original Medicare Plan is a "fee-for- 
service" plan. You are charged a fee for each health care service or supply you 
get. This plan, managed by the Federal Government, is available nationwide. 
You will stay in the Original Medicare Plan unless you choose to join a 
Medicare + Choice Plan. Many people in the Original Medicare Plan also buy a 
Medigap (Medicare Supplement Insurance) policy to help pay health care 
costs that this plan doesn't cover. 



Medicare + Choice Plans (pronounced "Medicare plus Choice") - 
Medicare + Choice Plans provide care under contract to Medicare. There are 
two types of Medicare + Choice Plans. They are available in many parts of the 
country. 

Medicare + Choice Plans include the following: 

• Medicare Managed Care Plans (like HMOs and PPOs), and 

• Medicare Private Fee-for-Service Plans. 



. 



Important: If you belong to a Medicare + Choice Plan, the plan must cover at 
least the same benefits as Medicare Part A and Part B. However, your costs may be 
different, and you may have extra benefits, like coverage for prescription drugs or 
additional days in the hospital. 



Words in 
purple are 
defined on 

pages 82-85. 



It is important to know how you get your Medicare health care. To learn more 
about Medicare, look at your copy of the Medicare & You handbook (CMS Pub. 
No. 10050), which is mailed each fall to people with Medicare. You can order a 
copy by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. You can also read or print a copy of this handbook at 
www.medicare.gov on the web. Select "Publications." 



4 



Section 1: A Quick Look At Medicare 



Medicare Part A 

Medicare Part A (Hospital Insurance) helps pay for the following: 



For more 
information on 
what Medicare 
Part A covers, 
see the 

coverage chart 
on page 69. 



For more 
information on 
what Medicare 
Part B covers, 
see the 
coverage 
charts on 
pages 70-72. 



• Inpatient hospital care, 

• Skilled nursing facility care, 

• Hospice care, and 

• Some home health care. 
How To Get Medicare Part A 

If you are already getting Social Security or Railroad Retirement 
benefits you will get Medicare Part A automatically when you turn 
age 65. If you are close to age 65 and are not yet getting Social 
Security or Railroad Retirement benefits or Medicare Part A, you 
can apply for both at the same time. You can also apply for 
Medicare Part A only. You will not pay a monthly payment called a 
premium for Medicare Part A because you or your spouse paid 
Medicare taxes while working. This is called premium-free 
Medicare Part A. 

If you (or your spouse) didn't pay Medicare taxes while you 
worked, and you are age 65 or older, you still may be able to buy 
Medicare Part A. If you aren't sure if you have Medicare Part A, 
look on your red, white, and blue Medicare card. It will show 
"Hospital (Part A)" on the lower left corner of the card. You can 
also call the Social Security Administration at 1-800-772-1213 or 
call your local Social Security office for more information about 
buying Medicare Part A. If you get benefits from the Railroad 
Retirement Board (RRB), call your local RRB office or 
1-800-808-0772. 



Medicare Part B 



Medicare Part B (Medical Insurance) helps pay for the following: 

• Doctors' services, 

• Outpatient hospital care, and 

• Some other medical services that Medicare Part A doesn't 
cover (like some home health care including durable medical 
equipment). 

Medicare Part B helps pay for these covered services and supplies 
when they are medically necessary. 






Section 1: A Quick Look At Medicare 



How To Get Medicare Part B 

You are automatically eligible for Medicare Part B if: 

• You are eligible for premium-free Medicare Part A, or 

• You are a United States citizen or permanent resident age 65 
or older. 

Just before you turn 65 years old, you have to decide whether or not to 
enroll in Medicare Part B. If you are already getting Social Security 
benefits, Medicare will enroll you in Medicare Part B automatically. 
You should keep in mind that the cost of Medicare Part B will go up 
10% for each 12-month period that you could have had Medicare 
Part B but didn't sign up for it, except in special cases (see pages 7-8, 
"The Special Enrollment Period For Medicare Part B"). 

If you choose to enroll in Medicare Part B, you pay the Medicare 
Part B premium of $58.70 per month (in 2003). Rates can change 
every year. For some people, this amount may be higher if they didn't 
choose Medicare Part B when they first became eligible at age 65. 

The premium is usually taken out of your monthly Social Security, 
Railroad Retirement, or Civil Service Retirement payment. In these 
cases, you won't get a bill for your premium. If you don't get any of 
these payments, Medicare sends you a bill for your Medicare Part B 
premium every three months. If you don't get your bill by the 10th of 
the month, call the Social Security Administration at 1-800-772-1213. 
If you get benefits from the Railroad Retirement Board (RRB), call 
your local RRB office or 1-800-808-0772. 

If you didn't sign up for Medicare Part B when you were first eligible, 
you may sign up during two enrollment periods: 

• The General Enrollment Period, see page 7, and 

• The Special Enrollment Period, see pages 7-8. 



Section 1: A Quick Look At Medicare 



The General Enrollment Period For Medicare Part B 

This period runs from January 1 through March 3 1 of each 
year. During this time, you can sign up for Medicare Part B at 
your local Social Security office. If you get benefits from the 
Railroad Retirement Board (RRB), call your local RRB office 
or 1-800-808-0772. Your Medicare Part B coverage will start 
on July 1 of the year you sign up. Remember, the cost of 
Medicare Part B will go up 10% for each 12-month period that 
you could have had Medicare Part B but didn't take it, except 
in special cases (see below). You will have to pay this extra 
amount for as long as you have Medicare Part B. 

The Special Enrollment Period For Medicare Part B 

This period is available if you waited to enroll in Medicare 
Part B because you or your spouse were working and had 
group health coverage through an employer or union based on 
this current employment. Most people who sign up for 
Medicare Part B during a Special Enrollment Period don't pay 
higher premiums. 

If this applies to you, you can sign up for Medicare Part B: 

• Any time you are still covered by an employer or union 
group health plan, through your or your spouse's current or 
active employment, or 

• During the eight months following the month that the 
employer or union group health plan coverage ends, or when 
the employment ends (whichever is first). 

Note: If you are still working and plan to keep your employer's 
group health coverage, you should talk to your benefits 
administrator to help you decide when is the best time to enroll 
in Medicare Part B. When you sign up for Medicare Part B, 
you automatically begin your Medigap open enrollment 
period. Once your Medigap open enrollment period begins, it 
cannot be changed or restarted. See pages 18-20 to learn more 
about your Medigap open enrollment period. 



Section 1: A Quick Look At Medicare 



The Special Enrollment Period For Medicare Part B (continued) 



If you are disabled and working (or you have coverage from a 
working family member), the Medicare Part B Special 
Enrollment Period rules may also apply. 

Remember, most people who sign up for Medicare Part B 
during a Special Enrollment Period don't pay higher premiums. 
However, if you are eligible but don't sign up for Medicare 
Part B during the Special Enrollment Period, you will only 
be able to sign up during the General Enrollment Period 
(see page 7), and the cost of Medicare Part B may go up. 



For more information about signing up for Medicare 
Part A and Part B, call the Social Security Administration 
at 1-800-772-1213. TTY users should call 1-800-325-0778. 
If you get benefits from the Railroad Retirement Board, 
call your local RRB office or 1-800-808-0772. 

If you have End-Stage Renal Disease (ESRD), different 
rules for enrollment may apply. For more information 
about ESRD, get a free copy of Medicare Coverage of 
Kidney Dialysis and Kidney Transplant Services (CMS 
Pub. No. 10128). Look at www.medicare.gov on the web. 
Select "Publications." Or, you can call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. 



8 



Section 2: 

Medigap Policy 

Basics 




"This section gave me the basic information 
I needed to know to buy a Medigap 
policy." 



Section 2: Medigap Policy Basics 



What Is A Medigap Policy? 



If you live in 
Massachusetts, 
Minnesota, or 

Wisconsin, different 
types of standardized 
Medigap plans are 
sold in your state. 
For more 
information, see 
pages 73-75. 



A Medigap policy is a health insurance policy sold by private insurance 
companies to fill the "gaps" in Original Medicare Plan coverage. 

There are ten standardized Medigap plans called "A" through "J." The 
front of a Medigap policy must clearly identify it as "Medicare 
Supplement Insurance." Each plan A through J has a different set of 
benefits. Plan A covers only the basic (core) benefits (listed on 
page 14). These basic benefits are included in all the Plans, A through J. 
Plan J offers the most benefits. 

When you buy a Medigap policy, you pay a premium to the insurance 
company. This premium is different than the Medicare Part B premium 
you must also pay. As long as you pay your premium, your policy is 
guaranteed renewable, which means it is automatically renewed each 
year. Your coverage will continue year after year as long as you pay your 
premium. If you buy a Medigap policy, it only covers your health care 
costs. It doesn't cover any health care costs for your spouse. 

Important: In some states, insurance companies may refuse to renew a 
Medigap policy bought before 1990. At the time these policies were 
sold, state law was not required to say the Medigap policies had to be 
renewed automatically each year. 

Medigap policies only help pay health care costs if you have the Original 
Medicare Plan. You don't need to buy a Medigap policy if you are in a 
Medicare + Choice Plan. In fact, it is illegal for anyone to sell you a 
Medigap policy if they know you are in one of these plans. 

It is also illegal for an insurance company to sell you a Medigap policy 
if you have Medicaid except in certain situations (see page 60). 



10 



Section 2: Medigap Policy Basics 



What Is Not A Medigap Policy? 

A Medigap policy is not: 

Coverage you get from your employer or union, 
A Medicare + Choice Plan, 
Medicare Part B, and 
Medicaid. 

Who Can Buy A Medigap Policy? 

To buy a Medigap policy, you generally must have Medicare Part A 
and Part B. If you are under age 65 and you are disabled or have 
End- Stage Renal Disease (ESRD), you may not be able to buy a 
Medigap policy until you turn 65. 

More information about Medigap policies for people under age 65 
starts on page 38. 

Can I Keep Seeing The Same Doctor If I Buy A Medigap 
Policy? 

In most cases, yes. If you are in the Original Medicare Plan 
and you have a Medigap policy, you can go to any doctor, 
hospital, or other health care provider who accepts Medicare. 
However, if you have the type of Medigap policy called 
Medicare SELECT, you must use specific hospitals and, in 
some cases, specific doctors to get your full insurance benefits. 

What Is Medicare SELECT? 

Medicare SELECT is a type of Medigap policy available in 
some states. If you buy a Medicare SELECT policy, you are 
buying one of the ten standardized Medigap plans A through J. 
With a Medicare SELECT policy, you must use specific 
hospitals and, in some cases, specific doctors to get full 
insurance benefits (except in an emergency). For this reason, 
Medicare SELECT policies generally cost less than other 
Medigap policies. 



Words in purple 
are defined on 
pages 82-85. 



11 



Section 2: Medigap Policy Basics 



Why Would I Want To Buy A Medigap Policy? 

You may want to buy a Medigap policy because Medicare 
doesn't pay for all of your health care. There are "gaps" or 
costs that you must pay in the Original Medicare Plan. The 
chart on page 13 gives some examples of these gaps. 
Remember, no Medigap policy will cover all the gaps in the 
Original Medicare Plan. 

If you are in the Original Medicare Plan, a Medigap policy may 
help you: 

• Lower your out-of-pocket costs, and 

• Get more health insurance coverage. 

What you pay out-of-pocket in the Original Medicare Plan will 
depend on the following: 

• Whether your doctor or supplier accepts "assignment" 
which means takes Medicare's approved amount as 
payment in full, 

• How often you need health care, 

• What type of health care you need, 

• Whether you buy a Medigap policy, 

• Which Medigap policy you buy, and 

• Whether you have other health insurance. 






You don't need a Medigap policy if you are in a Medicare + Choice Plan. 



12 



Section 2: Medigap Policy Basics 



Some examples 


of Gaps in Medicare covered services 
WhatYOUPayin2003 


A Medigap Poli< 
May Help Pay 
These Costs 


Hospital Stays 


• $840 for the first 60 days 

• $210 per day for days 61-90 

• $420 per day for days 91-150 


/ 


Skilled Nursing 
Facility Stays 


• Up to $105 per day for days 21-100 


/ 


Blood 


• Cost of the first 3 pints 


/ 


Medicare 
Part B yearly 
deductible 


• $100 per year 


/ 


Medicare 
PartB 
covered 
services 


• 20% of Medicare-approved amount for 
most covered services 

• 50% of the Medicare-approved amount for 
outpatient mental health treatment* 

• Copayment for outpatient hospital services 


/ 



* All Medigap policies must pay 50% coinsurance for outpatient mental health 
treatment services. 

Note: Some Medigap policies also cover other extra benefits that aren't covered by 
Medicare. Some examples of these benefits include the following: 

• Routine yearly check-ups, 

• At-home recovery, 

• Medicare Part B excess charges (the difference between your 
doctor's charge and Medicare's approved amount). The excess 
charge only applies if your doctor doesn't accept assignment, 

• Prescription drugs, 

• And more (see page 15). 



13 



Section 2: Medigap Policy Basics 



What Medigap Policies Don't Cover 

• Long-term care, 

• Vision or dental care, 

• Hearing aids, 

• Private-duty nursing, or 

• Unlimited prescription drugs. 

What Medigap Policies Cover 

Each standardized Medigap policy must cover basic (core) benefits 
(see below). Medigap policies pay most, if not all, of the Original 
Medicare Plan coinsurance and outpatient copayment amounts. These 
policies may also cover Original Medicare Plan deductibles. Some 
Medigap policies cover extra benefits to help pay for things Medicare 
doesn't cover (see page 15). 

Medigap Plans A through J Basic (Core) Benefits Include: 

• The Medicare Part A coinsurance amount for days 61-90 ($210 per day in 
2003), and days 91-150 ($420 per day in 2003) of a hospital stay, 

• Coverage of up to 365 more days of a hospital stay during your lifetime after 
you use up all Medicare hospital benefits, 

• The coinsurance or copayment amount for Medicare Part B services 
after you meet the $100 yearly deductible (in 2003), and 

• The first three pints of blood or equal amounts of packed red blood 
cells per calendar year, unless this blood is replaced. 

See page 1 5 for more information about Medigap plans A through J. 



If you live in Massachusetts, Minnesota, or Wisconsin, see pages 73-75. 



14 



Section 2: Medigap Policy Basics 





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15 



Section 2: Medigap Policy Basics 



How Much Do Medigap Policies Cost? 

The cost of Medigap policies varies widely. The cost can vary by: 

• Your age, 

• Where you live, and 

• The insurance company. 

Insurance companies have three different ways of pricing policies. 
For details about these three ways, see pages 34-35. Although this 
Guide can't provide actual costs of Medigap policies, there is some 
information about Medigap costs in the Medicare Personal Plan 
Finder at www.medicare.gov on the web. This tool is described in 
detail on page 40. 

There can be big differences in the premiums that insurance 
companies charge for exactly the same coverage. As you shop for 
a Medigap policy, you will need to call insurance companies that sell 
Medigap policies in your state and ask about prices. When you 
compare premiums, be sure you are comparing the same Medigap 
policies. 

Other Factors That May Affect Your Cost 

• Whether you are male or female. 

Some companies offer discounts for females. 

• Whether you smoke. 

Some companies offer discounts for non-smokers. 

• Whether you are married. 

Some companies offer discounts for married couples. 

• Whether the insurance company uses medical underwriting. 

This is a process that an insurance company uses to review your 
health and medical history, and decide whether to accept your 
application for insurance, how much to charge you and whether to 
make you wait for some benefits. 

With medical underwriting, you usually must answer medical 
questions on an application. You need to fill out this application 
carefully and completely or your policy could be invalid. Some 
companies may want to review your medical record before they 
sell you a policy. The company can use this information to decide 
how much to charge you for a Medigap policy and to add a 
waiting period for pre-existing conditions if your state law allows 
(see page 36). 



16 



Section 2: Medigap Policy Basics 



Other Factors That May Affect Your Cost (continued) 

• Whether the insurance company uses medical 
underwriting, (continued) 

Insurance companies may "medically underwrite" any 
Medigap policy unless you are in your Medigap open 
enrollment period (see page 1 8) or you have special rights 
to buy a Medigap policy (see page 41). 

• Whether you buy a High Deductible Option Policy. 

Insurance companies may offer a "high deductible option" on 
Medigap Plans F and J (see chart on page 15). If you choose 
this option, you must pay a $1,650 deductible for the year 
2003 before the policy pays anything. This amount can go up 
each year. 

High deductible option policies often cost less, but if you get 
sick, your out-of-pocket costs will be higher and you may not 
be able to change plans. 

In addition to the $1,650 (in 2003) deductible that you must 
pay for the high deductible option on Plans F and J, you must 
also pay deductibles for: 

• Prescription drugs ($250 per year for Plan J), and 

• Foreign travel emergency ($250 per year for Plans F and J). 



Words in purple are 
defined on pages 82-85. 



Whether you buy a Medicare SELECT Policy. 

If you have a Medicare SELECT policy and you don't use a 
Medicare SELECT hospital or doctor for non-emergency 
services, you will have to pay some or all of what Medicare 
doesn't pay. Medicare will pay its share of approved charges 
no matter what hospital or doctor you choose. 



17 



Section 2: Medigap Policy Basics 



When Is The Best Time To Buy A Medigap Policy? 

The best time to buy a Medigap policy is during your Medigap 
open enrollment period. 

Your Medigap open enrollment period lasts for six months. It 
starts on the first day of the month in which you are both: 

• Age 65 or older, and 

• Enrolled in Medicare Part B. 

Once the six-month Medigap open enrollment period starts, it 
can't be changed. 

During this period, an insurance company can't: 

• Deny you insurance coverage, 

• Place conditions on a policy (like making you wait for 
coverage to start), or 

• Charge you more for a policy because of past or 
present health problems. 



Words in purple are 
defined on pages 82-85. 



If you buy a Medigap policy during your Medigap open 
enrollment period, the insurance company must shorten the 
waiting period for pre-existing conditions by the amount of 
previous health coverage you have. This is called "creditable 
coverage." 

See page 36 for more information about pre-existing 
conditions. If you want to know more about creditable 
coverage, see page 37. If you are disabled or have End-Stage 
Renal Disease (ESRD), see pages 38-40. 

You can tell if you are in your Medigap open enrollment period 
by looking at your red, white, and blue Medicare card. This 
card shows the dates that your Medicare Part A and Part B 
coverage started. If you are age 65 or older, add six months to 
the date that your Medicare Part B coverage starts. If that date 
is in the future, you are still in your Medigap open enrollment 
period. If that date is in the past, you have missed your 
Medigap open enrollment period (see example on page 19). 



18 



Section 2: Medigap Policy Basics 



When Is The Best Time To Buy A Medigap Policy? 
(continued) 



Example: Medigap Open Enrollment Period 

It is October 1, 2003, and Mr. Rodriguez wants to buy a 
Medigap policy. He needs to know if he is in his Medigap 
open enrollment period. He looks at his Medicare card. His 
Medicare Part B coverage started August 1, 2003. To figure 
out if he is in his open enrollment period, he must add six 
months to his Medicare Part B start date and see if it is 
before or after the current date. 

August 1, 2003 + six months = January 31, 2004 

Since it is October 1, 2003, he is still in his open enrollment 
period. Mr. Rodriguez has until January 31, 2004, to buy any 
Medigap policy during his Medigap open enrollment period. 



What If I Missed My Medigap Open Enrollment Period? 

If you apply for a Medigap policy after your open enrollment 
period has ended, the Medigap insurance company is allowed 
to use medical underwriting to decide whether to accept your 
application, and how much to charge you for the policy. If you 
are in good health, the insurance company is likely to accept 
your application, but there is no guarantee that you will get the 
policy. 



19 



Section 2: Medigap Policy Basics 



Should I Enroll In Medicare Part B And Start My 
Medigap Open Enrollment Period If I Am Age 65 Or 
Older And Still Working? 

You may want to wait to enroll in Medicare Part B if you or 
your spouse are working and have group health coverage 
through an employer or union based on your or your spouse's 
current or active employment. Your Medigap open 
enrollment period won't start until you sign up for 
Medicare Part B. Remember, once you're age 65 or older and 
enrolled in Medicare Part B, the Medigap open enrollment 
period starts and can't be changed. 



Steps To Buying A Medigap Policy 

Buying a Medigap policy is an important decision. Only you 
can decide if a Medigap policy is the right kind of health 
insurance coverage for you. If you decide to buy a Medigap 
policy, shop carefully. Look for a policy that you can afford 
and that gives you the coverage you need most. As you shop 
for a Medigap policy, keep in mind that different insurance 
companies may charge different amounts for the same type of 
Medigap policy. 

The steps to buy a Medigap policy include the following: 

Step 1 : Look at how much you are spending on health care 
each year (see pages 21-22). 

Step 2: Think about your future health care needs, review the 
Medigap plans, and decide which benefits you need or 
want (see pages 23-26). 

Step 3 : Find out which insurance companies sell Medigap 
policies in your state (see page 27). 

Step 4: Call the insurance companies and compare costs 
(see pages 28-29). 

Step 5: Choose the best Medigap policy for you (see page 30). 

Step 6: Buy the Medigap policy (see page 31). 



20 



Section 2: Medigap Policy Basics 




Step 1. Look at how much you are spending on health 
care each year. 

Use the worksheet on page 22 to write down your yearly 
expenses for health care. If you don't know your yearly expenses, 
use the worksheet to check off the health care costs and services 
you paid for (called out-of-pocket costs) (see "How To Use The 
Worksheet" below). This will help you decide which Medigap 
policy benefits you need. It will also help you when you begin to 
shop for the Medigap policy that is right for you. 

Important: If you are currently in a health plan that pays for the 
cost of these services, you may not know how much these services 
cost. However, you should think about your current and future 
health care needs, and place a check mark next to those items you 
think you may need. As you get older, your health care costs may 
increase. 

How To Use The Worksheet 
Column 1 

• This column lists types of health care services that you may 
have paid for over the last few years. You can also add other 
health care services that you paid for in the past that you may 
want to think about when choosing a Medigap policy. Write 
those services in the row marked "Other." 

Column 2 

• Write down the cost for the services you used and paid for over 
the last few years, or place a check mark for health care costs 
you paid for. 



Words in purple are 
defined on pages 82-85. 



Look at the amounts in Column 2. Rows with the largest dollar 
or cost amounts are most likely the benefits you may need in a 
Medigap policy right now. Remember, you should also think 
about your future health care needs (see pages 24-25). For 
example, let us say you didn't have a hospital stay last year, so 
you didn't have to pay a Medicare Part A hospital deductible. 
Next year, or sometime in the future, you may end up in a 
hospital. If you didn't buy a Medigap policy that covers the 
Medicare Part A hospital deductible, you will have to pay this 
cost for each benefit period ($840 in 2003). 



21 



Section 2: Medigap Policy Basics 




Yearly Health Care Cost Worksheet 

Column 1 Column 2 



22 



Health Care Services 


How Much You Paid Last Year | 
(Write down dollar amount or j 
check if you paid last year.) 


Skilled Nursing Coinsurance 

Up to $105 a day (in 2003) for days 
21-100 in a Skilled Nursing Facility. 


$ 


Medicare Part A Hospital Deductible 

This amount ($840 in 2003), for days 1-60 of 
a hospital stay, can change every year. 


$ 


Medicare Part B Yearly Deductible 

$100 per year in 2003. 


$ 


Medicare Part B Excess Charge 

This is the difference between your doctor's 
actual charge and Medicare's approved amount. 


$ 


Foreign Travel Emergency 

Any emergency care you received outside of 
the United States. 


$ 


At-Home Recovery 

Help you receive at home with activities of 
daily living, like bathing and dressing, when 
you are already getting Medicare-covered 
home health visits. 


$ 


Prescription Drugs 


$ 


Preventive Care 

Such as routine yearly check-ups, serum 
cholesterol screening, hearing tests, 
diabetes screening, and thyroid function 
tests. 


$ 


Other 


$ 



Section 2: Medigap Policy Basics 




Step 2. Think about your future health care needs, review 
the Medigap plans, and decide which benefits you 
need or want. 

If you decide to buy a Medigap policy, make sure it covers the benefits 
you want or need. You should also think about benefits you may need 
in the future. Think about your medical history, your family medical 
history, and health risks when thinking about future health care costs. 

On the next two pages you will find a worksheet you can use. If you 
complete this worksheet, you should have a good idea of the types of 
benefits you want to look for in a Medigap policy. The worksheet 
includes a list of extra benefits that different Medigap policies cover. 
Next to each benefit is a reason why you might want or need that benefit. 

1 . Put a check mark in the column "Do I need or want these extra 
benefits?" next to the extra benefits you need or want. 

2. Turn to the chart on page 15 that lists all the Medigap plans and their 
benefits. On that chart, circle the benefits you checked on the 
worksheet. 

3. Look at the benefits you circled on page 15, and find the plan that has 
most, if not all, of the benefits you need or want. Remember, all of the 
plans cover the basic benefits (see below). The plan you choose may 
not match your needs exactly. You may have to give up or buy extra 
benefits to get a plan that is close to what you want. 

These basic (core) benefits are included in all Medigap policies: 

• The Medicare Part A coinsurance amount for days 61-90 ($210 per day in 
2003), and days 91-150 ($420 per day in 2003) of a hospital stay, 

• Coverage of up to 365 more days of a hospital stay during your 
lifetime after you use up all Medicare hospital benefits, 

• The coinsurance or copayment amount for Medicare Part B services 
after you meet the $100 yearly deductible (in 2003), and 

• The first three pints of blood or equal amounts of packed red blood 
cells per calendar year, unless this blood is replaced. 



23 



Section 2: Medigap Policy Basics 



Medigap policy extra benefits 


Reasons you might need or 
want these extra benefits 


Do 1 need or want 
these extra benefits? 


Skilled Nursing Coinsurance 

Up to $105 a day (in 2003) for days 
21-100 in a Skilled Nursing Facility. 


You may need this benefit if you have 
to go to a Skilled Nursing Facility 
(SNF) after a hospital stay and stay in 
the SNF longer than 20 days. 




Medicare Part A Hospital 
Deductible 

This amount ($840 in 2003), for 
days 1 -60 of a hospital stay, can 
change every year. 


You may need this benefit if you have 
to stay in the hospital. You have to pay 
the Medicare Part A deductible each 
benefit period. 




Medicare Part B Yearly Deductible 

$100 per year in 2003. 


You may want to think about this 
benefit if you have Medicare Part B. 
Each year you must pay the Medicare 
Part B deductible before Medicare 
starts to pay its share. If you have this 
benefit, the Medigap policy would 
pay this amount each year. 




Medicare Part B Excess Charge 

This is the difference between your 
doctor's actual charge and 
Medicare's approved amount, if your 
doctor doesn't accept assignment. 
Plans F, I, and J pay all of the excess 
charges. Plan G pays 80% of the 
excess charges. 


You may want to think about this 
benefit if your doctors don't accept 
assignment. You may also want this 
benefit if you have to stay in the 
hospital and can't control whether the 
doctors you see accept assignment. 
Under federal law, doctors who don't 
take Medicare's approved amount as 
payment in full (accept "assignment"), 
may charge up to 15% more than the 
approved amount. Your state may have 
different laws. 




Foreign Travel Emergency 

80% of the cost of emergency care 
during the first 60 days of each trip 
(after the $250 deductible). 
Up to $50,000 in your lifetime. 


You may want to think about this 
benefit if you travel outside the 
United States. This benefit could save 
you money if you need emergency 
care. 





24 





Section 2: Medigap Policy Basics 


Medigap policy extra benefits 


Reasons you might need or 
want these extra benefits 


Do 1 need or want these 
extra benefits? 


At-Home Recovery 

This is the cost of at-home help 
with activities of daily living, 
like bathing and dressing, if you 
are already getting Medicare- 
covered home health visits. 

Up to eight weeks of at-home 
help after skilled nursing care is 
no longer needed. 

Will pay up to $40 each visit 
and $ 1 ,600 each year. 


This benefit covers additional 
care at home if you are already 
getting Medicare-covered home 
health services. This benefit 
may add to the cost of the 
policy. 




Prescription Drugs 

50% of the drug costs that 
Medicare doesn't cover (after 
you pay a $250 per year 
deductible). 

Up to $1,250 each year under 
Plans H and I (Basic drug 
benefit). 

Up to $3,000 each year under 
Plan J (Extended drug benefit). 


You may want to think about 
this benefit if you have high 
prescription drug costs. It covers 
half your drug costs after the 
yearly deductible up to a 
maximum amount. Therefore, to 
get the full benefit under Plans H 
and I, you should have at least 
$2,750 in drug costs in a year (you 
pay $1,250 plus $250; plan pays 
$1,250). To get the full benefit 
under Plan J, you should have at 
least $6,250 in drug costs in a year 
(you pay $3,000 plus $250; plan 
pays $3,000). 




Preventive Care 

Such as routine yearly check- 
ups, serum cholesterol 
screening, hearing tests, 
diabetes screening, and thyroid 
function tests. 

Up to $120 each year. 


This benefit helps pay for 
routine yearly check-ups and 
tests that may be important to 
keep you healthy. 





25 



Section 2: Medigap Policy Basics 



Step 2. Think about your future health care needs, 
review the Medigap plans, and decide which 
benefits you need or want, (continued) 

Now that you have completed the worksheet (listed on pages 
24-25) and have circled the benefits you need or want on the 
chart (listed on page 15), you should have a good idea of what 
Medigap plans best fit your needs. Next, you will need to find 
out which insurance companies sell Medigap policies in your 
state. Step 3 explains how to find this information (see page 27). 

If you need more information about which Medigap policy is 
best for you, call your State Health Insurance Assistance 
Program (see pages 79-80). 



If you live in Massachusetts, Minnesota, or Wisconsin, see 
pages 73-75. 



26 



Section 2: Medigap Policy Basics 





Step 3. Find out which insurance companies sell 
Medigap policies in your state. 

To find out which insurance companies sell Medigap policies 
in your state, you can do any of the following: 



• Call your State Health Insurance Assistance Program 
(see pages 79-80). Ask if they have a Medigap rate 
comparison shopping guide for your state. These types 
of guides usually list the insurance companies that sell 
Medigap policies in your state and compare the costs of 
policies for each company. 

• Call your State Insurance Department (see pages 79-80). 

• Look at www.medicare.gov on the web. Select 
"Medicare Personal Plan Finder" (see page 40). 

This website will help you find information on all 
your health plan options, including Medigap policies 
in your area. You can also get information on the 
following: 

/ Some companies that sell Medigap policies in your 
state, 

/ What the policies must cover, and 

/ How insurance companies decide what to charge you 
for a Medigap policy premium. 

If you don't have a computer, your local library or 
senior center may be able to help you look at this 
information. 

• Call 1-800-MEDICARE (1-800-633-4227). For English, 
press (1) or for Spanish, press (2). Select option "0." A 
Customer Service Representative will help you get 
information on all your health plan options, including 
Medigap policies in your area. You will get your 
Medicare Personal Plan Finder results in the mail within 
three weeks. TTY users should call 1-877-486-2048. 

You should plan to call more than one insurance company 
that sells Medigap policies in your state. Make sure the ones 
you choose to call are honest and reliable (see page 55). 



27 



Section 2: Medigap Policy Basics 



Step 4. Call the insurance companies and compare costs. 

Call different insurance companies and ask questions (see page 29). 
Friends and relatives can tell you about their policies, but their policies 
may not fit your needs. Shop around for the best Medigap policy for 
you at a price you can afford. 



If you aren't in your Medigap open enrollment period or in 
another situation where you have a guaranteed issue right to 
buy a Medigap policy (see pages 41-48), ask questions. You 
should ask each insurance company the questions listed on 
page 29. 





#/ 


JT 



Use the comparison worksheet on page 29 to write down 
the insurance company answers. This will help you 
compare costs and benefits you are considering. 



28 



Section 2: Medigap Policy Basics 



Medigap Policy Comparison Worksheet 

Use this worksheet to compare costs and benefits you are considering. Make sure you get the 
agents' and the companies' names, addresses, and telephone numbers. 



Ask each insurance 
company 


Insurance 
Company 1 


Insurance 
Company 2 


Insurance 
Company 3 


Is this insurance company licensed in this 
state? (The answer should be yes.) 








Which Medigap policies do you sell? (Make 
sure they sell the plan you want.) 








What is the cost, this year, of the Medigap 
policy I am interested in? What has been the cost 
of this Medigap policy for the past few years? 








How is the price decided? 

• What type of pricing does this insurance 
company use? 

• Does it make a difference if I am male or 
female? 

• Does it make a difference if I smoke or 
don't smoke? 

• Does it make a difference if I am married or 
single? 








Are there any additional ("innovative") benefits 
or discounts included in this policy? 








If you aren't in your Medigap open enrollment 
period or in another situation where you have 
a guaranteed issue right, ask: 

• Will you accept my application? 

• Do you review my health records or 
application to decide how much to charge 
me for a Medigap policy? 

• Will I have to wait for my pre-existing 
conditions to be covered if I already have a 
health problem? 






29 



Section 2: Medigap Policy Basics 



Step 5. Choose the best Medigap policy for you. 




After you call the insurance companies and compare their 
costs, choose the Medigap policy that is best for you. 

But, before you make your final choice, make sure of the 
following: 

□ You carefully review the Medigap policy benefits. 

□ You can afford the cost of the policy. 

□ The policy covers the benefits you need and want. 

You feel good about and trust the insurance company 
and/or the insurance agent. 

□ You talk with someone you trust, like a family 
member, friend, doctor, or insurance agent about 
your choice. 

Once you have checked the items above, you are now 
ready to move on to Step 6. 



30 



Section 2: Medigap Policy Basics 




Step 6. Buy the Medigap policy. 

Once you have decided on the insurance company and the 
Medigap policy you want, you can buy your policy. The 
insurance company must give you a clearly worded summary of 
your Medigap policy. Read it carefully. If you don't understand 
it, ask questions. Remember the following when you buy your 
Medigap policy: 

□ Fill out your application carefully and completely Answer 
all of the medical questions. If the insurance agent fills 
out the application, review it to make sure it's correct. 

□ Don't buy more than one Medigap policy. If you already 
have a Medigap policy, it is illegal for an insurance 
company to sell you a second policy unless you put in 
writing that you are going to cancel the first Medigap 
policy. However, don't cancel your first Medigap policy 
until the second one is in place, and you decide to keep the 
second Medigap policy. You have 30 days to decide if you 
want to keep the new policy. This is called your "free look" 
period. 

D Don't pay cash. Pay for your policy by check, money 
order, or bank draft. Make it payable to the insurance 
company, not the agent. 

□ Ask for your Medigap policy to become effective when you 
want coverage to start, or when your previous policy 
coverage ends. If, for any reason, the insurance company 
won't give you the start date you want, call your State 
Insurance Department (see pages 79-80). 

| Get a receipt with the insurance company's name, address, 
and telephone number for your records. 

□ Make sure you get a copy of your policy within 30 days. 
If you don't get your policy in 30 days, call your 
insurance company. If you don't get your policy in 60 
days, call your State Insurance Department (see pages 
79-80). 



31 



Notes 



"I keep this book on my shelf so I know 
where to find it if I have a question." 




32 



Section 3: 

More Detailed Medigap 

Policy Information 




"Before we bought a Medigap policy, we used 
this section to learn more about Medigap 
policies." 



33 



Section 3: More Detailed Medigap Policy Information 



Ways of Pricing Medigap Policies 

Insurance companies have three different ways of pricing Medigap policies 
based on your age: 

1 . No-age-rated (also called community-rated) 

2. Issue-age-rated 

3. Attained-age-rated 

1. No-age-rated (also called community-rated) policies 

These policies charge everyone the same rate no matter how old they are. 

I * Example: No-age-rated 

| Mrs. Smith pays the same monthly premium at each age plus any premium j 
! increases the company may charge because of inflation. 



Monthly Premium at Age 65 
Monthly Premium at Age 75 
Monthly Premium at Age 85 



$155 

$155 
$155 



2. Issue-age-rated policies 

The monthly premium for these policies is based on your age when you first buy 
the policy. The cost doesn't go up automatically as you get older. Your premium 
will be the same as anyone your age buying this policy for the first time. 



* Example: Issue-age-rated 






Mrs. Smith pays the same monthly premium depending 


on how old she is 


when she buys the policy. She also pays any additional 


premium increase the 


company may charge because of inflation. 






Buy Policy at Age 65 




Monthly Premium at Age 65 


$130 




Monthly Premium at Age 75 


$130 




Monthly Premium at Age 85 


$130 




Buy Policy at 


Age 75 




Monthly Premium at Age 75 


$165 




Monthly Premium at Age 85 


$165 




Buy Policy at 


Age 85 




Monthly Premium at Age 85 


$195 





34 



Section 3: More Detailed Medigap Policy Information 



Ways of Pricing Medigap Policies (continued) 

3. Attained-age-rated policies 

The monthly premiums for these policies are based on your age 
each year. These policies generally cost less at age 65, but their 
costs go up automatically as you get older. 

Caution: In general, attained-age-rated policies are cheaper 
than issue-age-rated policies the first few years you own the 
policy. However, rate increases for attained-age-rated policies 
are usually larger than rate increases for issue-age-rated 
policies. After a period of time, the premiums for an attained- 
age-rated policy will be higher than what the premiums would 
have been if you had an issue-age-rated policy. 



* Example: Attained-age-rated 




Mrs. Smith buys the policy at age 65. 


and pays higher monthly 


premiums as she gets older. She also 


pays any additional 


premium increases the company may 


charge because of 


inflation. 




Monthly Premium at Age 65 


$115 


Monthly Premium at Age 75 


$160 


Monthly Premium at Age 85 


$200 



Remember, all monthly premiums may change and go up 
each year because of inflation and rising health care costs. 
Also, the amounts shown in the examples aren't actual costs. 
Cost may vary. 



35 



Section 3: More Detailed Medigap Policy Information 



Medigap Coverage of Pre-existing Conditions 

What Is A Pre-existing Condition? 



A pre-existing condition is a health problem you had before the 
date a new insurance policy starts. 



Will My Pre-existing Condition Be Covered If I Buy A 
Medigap Policy? 

In some cases, a Medigap insurance company can refuse to 
cover health problems for up to six months, if you had the 
health problem before the policy started. This is called a 
"pre-existing condition waiting period." The insurance company 
can only use this kind of waiting period if your health problem 
was diagnosed or treated during the six months before the policy 
started. This means that the insurance company can't make you 
wait for coverage of a pre-existing condition just because it 
thinks you should have known to see a doctor for a health 
problem. 

Open Enrollment Period 

If you buy a policy during your Medigap open enrollment 
period, and you had at least six months of previous health 
coverage that qualifies as "creditable coverage" (see page 37), 
the company cannot give you any pre-existing condition waiting 
period. If you had less than six months of creditable coverage, 
this waiting period will be reduced by the number of months of 
creditable coverage you had. 

Special Medigap Protections (Guaranteed Issue Rights) 

If you buy a Medigap policy when you have special Medigap 
protections or guaranteed issue rights, the insurance company 
can't use a pre-existing condition waiting period (see page 41). 



Words in purple are 
defined on pages 82-85. 



If you want to know if you will have a pre-existing condition 
waiting period if you switch Medigap policies, see page 50. 



36 



Section 3: More Detailed Medigap Policy Information 



Creditable Coverage 

What Is Creditable Coverage? 

Creditable coverage is any previous health coverage you have that can reduce the 
time you have to wait before your pre-existing health conditions will be covered 
by a policy you buy during your Medigap open enrollment period. 

Your previous health coverage could have been any of the following: 

• A group health plan (like an employer plan) 

• A health insurance policy 

• Medicare Part A or Medicare Part B 

• Medicaid (see page 60) 

• A medical program of the Indian Health Service or tribal organization 

• A state health benefits risk pool 

• TRICARE (the health care program for military dependents and retirees 
[see pages 65-66]) 

• A Federal Employees Health Benefit Plan 

• A public health plan 

• A health plan under the Peace Corps Act 

Note: Whether you can use creditable coverage depends on whether you had any 
"breaks in coverage." If there was any time when you had no health coverage of any 
kind, and, during that time, you were without coverage for more than 63 days in a row, 
you can only count creditable coverage that you had after that break in coverage. 



Example: Creditable Coverage 

Mr. Smith is 65 and has heart disease. His Medicare Part A and Part B started 
November 1, 2002. Before this date, he had no health insurance coverage. On 
March 1, 2003, Mr. Smith buys a Medigap policy. His Medigap insurance 
company refuses to cover his heart disease condition for six months (the 
pre-existing condition waiting period). However, since Mr. Smith had 
Medicare Part A and Part B from November 1 to March 1 , the insurance 
company must use his four months of Medicare coverage as creditable 
coverage to shorten this six-month waiting period. Now his waiting period will 
only be two months instead of six months. During these two months, after 
Medicare pays its share, Mr. Smith will have to pay the rest of the costs for 
the care of his heart disease. He will also have to pay his Medigap premiums. 

37 
r2 



Section 3: More Detailed Medigap Policy Information 



Medigap Policies For People Under Age 65 With 
A Disability or End-Stage Renal Disease (ESRD) 

You may have Medicare before age 65 due to the following: 

• A disability, or 

• ESRD (permanent kidney failure requiring dialysis or 
a kidney transplant). 

If you are under age 65 and disabled or have ESRD, you may 
not be able to buy the Medigap policy you want until you turn 
65. Federal law doesn't require insurance companies to sell 
Medigap policies to people under age 65. However, some 
states require insurance companies to sell you a policy, at 
certain times, even if you are under age 65. 

During the first six months after you turn age 65 and are 
enrolled in Medicare Part B, you will get a Medigap open 
enrollment period. It doesn't matter that you have had 
Medicare Part B before you turned age 65. During this time: 

• You can buy any Medigap policy (including those 
policies that help pay the cost of prescription drugs), and 

• Insurance companies cannot refuse to sell you a 
Medigap policy due to a disability or other health 
problem, or charge you a higher premium than they 
charge other people who are 65 years old. 

When you buy a policy during your Medigap open enrollment 
period, the insurance company must shorten the waiting period 
for pre-existing conditions by the amount of creditable 
coverage you have. If you had Medicare for more than six 
months before you turned 65 years old, you won't have a 
pre-existing condition waiting period because Medicare counts 
as creditable coverage. (See page 37 for more information 
about creditable coverage.) 

Several states require Medigap insurance companies to offer a 
limited Medigap open enrollment period for people with 
Medicare Part B who are under age 65. At the time of this 
printing, the following states require insurance companies to 

38 



Section 3: More Detailed Medigap Policy Information 



Medigap Policies For People Under Age 65 With 
A Disability or End-Stage Renal Disease (ESRD) 
(continued) 

offer at least one kind of Medigap policy during a special open 
enrollment period to people with Medicare under age 65 : 




'I wasn't sure if I 
could buy a 
Medigap policy, so 
I called my State 
Health Insurance 
Assistance 
Program. They 
were very helpful 
and answered all 
of my questions." 



California 

Connecticut 

Kansas 

Louisiana 

Maine 

Maryland 

Massachusetts 

Michigan 



Minnesota 
Missouri 
Mississippi 
New Hampshire 
New Jersey 
New York 
North Carolina 
Oklahoma 



• Oregon 

• Pennsylvania 

• South Dakota 

• Texas 

s Washington 

• Wisconsin 



Also, some insurance companies will sell Medigap policies to 
people with Medicare under age 65. However, these policies 
may cost you more. Remember, if you live in a state that has a 
Medigap open enrollment period for people under age 65, you 
will still get another Medigap open enrollment period when 
you turn age 65. 

Also, if you join a Medicare + Choice Plan and your coverage 
ends, you may have the right to buy a Medigap policy (see 
"Special Note For People With Medicare Under Age 65" on 
page 48). If you have questions, you should call your State 
Health Insurance Assistance Program (see pages 79-80). 

Right to suspend a Medigap policy for disabled people with 
Medicare 

If you are under 65, have Medicare, and have a Medigap 
policy, you have a right to suspend your Medigap policy. You 
can suspend your Medigap policy benefits and premiums, 
without penalty, while you are enrolled in your or your 
spouse's employer group health plan. 

If, for any reason, you lose your employer group health plan 
coverage, you can get your Medigap policy back. You must 
notify your Medigap insurance company that you want your 
Medigap policy back within 90 days of losing your employer 
group health plan coverage. 



39 



Section 3: More Detailed Medigap Policy Information 




"I used my computer 
to get a great start on 
my search for the right 
Medigap policy." 



Right to suspend a Medigap policy for disabled people with 
Medicare (continued) 

Your Medigap benefits and premiums will start again on the day your 
employer group health plan coverage stops. The Medigap policy must 
have the same benefits and premiums it would have had if you had never 
suspended your coverage. Your Medigap insurance company can't refuse 
to cover care for any pre-existing conditions you have. So, if you are 
disabled and working, you can enjoy the benefits of your employer's 
insurance without giving up your Medigap policy. 

Information on Medicare Health Plans and 
Medigap Policies 

Choosing the right health coverage is an important - but sometimes 
difficult - decision. The "Medicare Personal Plan Finder" helps you find 
information on your health plan options, including Medigap policies in 
your area. You will be able to get information about some of the 
insurance companies that sell Medigap policies in your state, how to 
contact these insurance companies, and, in some cases, how to compare 
your Medigap policy choices. 

You can get information three ways: 

1. Visit www.medicare.gov on the web for fast results. Select "Medicare 
Personal Plan Finder." 

2. Call 1-800-MEDICARE (1-800-633-4227). For English, press (1) or 
for Spanish, press (2). Select option "0." A Customer Service 
Representative will help you. You will get your Medicare Personal 
Plan Finder results in the mail within three weeks. 

3. Call your State Health Insurance Assistance Program (see pages 79-80). 
Ask if they have a Medigap rate comparison shopping guide for your state. 

Medicare Personal Plan Finder Results 

When you use the Medicare Personal Plan Finder, you will get a 
personalized summary page with general information to help you 
compare Medicare health plans and Medigap policies in your area. You 
can also get detailed information about the Medicare health plans and 
Medigap policies available in your area, or just the ones you are most 
interested in. You should plan to call more than one insurance company 
that sells Medigap policies in your state. Make sure the ones you call are 
licensed and reliable (see page 55). 



40 






Section 3: More Detailed Medigap Policy Information 



Medigap Rights and Protections (Guaranteed 
Issue Rights) 

Your Rights To Buy A Medigap Policy 

In some situations, you have the right to buy a Medigap policy 
outside of your Medigap open enrollment period. These rights 
are called "Medigap protections." They are also called 
guaranteed issue rights because the law says that insurance 
companies must sell you a Medigap policy. 



If you live in 
Massachusetts, 
Minnesota, or 
Wisconsin, you 

have the same 
guaranteed issue 
rights to buy a 
Medigap policy. 
If you have 
questions, call 
your State 
Insurance 
Department 
(see pages 79-80). 



In these situations, an insurance company: 

• Can't deny you Medigap coverage or place conditions on a 
policy (like making you wait for coverage to start), 

• Must cover you for all pre-existing conditions, and 

• Can't charge you more for a policy because of past or 
present health problems. 

In many cases, these rights also apply when your health coverage 
changes. Remember, it is best not to wait until your current 
health coverage has almost ended before you apply for a 
Medigap policy. You can apply for a Medigap policy early (for 
example, while you are still in your health plan) and choose to 
start your Medigap coverage the day after your health plan 
coverage ends. This will prevent gaps in your health coverage. 

Note: If you drop your Medigap policy, you may not be able to 
get it back except in very limited cases. 

Summary of Medigap Protections If You Lose or Drop Your 
Health Care Coverage (Guaranteed Issue Rights) 

The following page has a summary of these situations. In order 
to get these Medigap protections, you must meet certain 
conditions. More detailed information on each situation will 
follow the summary. All rights to buy Medigap policies in the 
following situations include Medicare SELECT policies since 
they are a type of Medigap policy. 

Note: There may be times when more than one situation applies 
to you. When this happens, you can choose the protection that 
gives you the best choice of Medigap policies. 



41 



Section 3: More Detailed Medigap Policy Information 



Summary of Medigap Protections (continued) 

Situation #1 : Your Medicare + Choice Plan or PACE program coverage ends 
because the plan is leaving the Medicare program or stops giving 
care in your area (see pages 43-44). 

Situation #2: Your employer group health plan coverage ends (see page 44). 

Situation #3: You have to end your health coverage because you move out of 
the plan's service area (see page 45). 

Situation #4: You joined a Medicare + Choice Plan or PACE program when 
you were first eligible for Medicare at age 65. Within the first 
year of joining, you decide you want to leave (see page 45). 

Situation #5: You dropped a Medigap policy to join a Medicare + Choice Plan, 
Medicare SELECT policy, or PACE program for the first time and 
now you want to leave. You have been in the plan less than a year 
(see page 46). 

Situation #6: Your Medigap insurance company goes bankrupt and you lose your 
coverage, or your Medigap policy coverage ends through no fault of 
your own (see page 46). 

Situation #7: You leave your plan because your Medicare + Choice Plan, 
Medicare SELECT, or Medigap insurance company has 
committed fraud. For example, the marketing materials were 
misleading, or quality standards were not met (see page 47). 



Important: In some situations, you have a guaranteed issue right to buy a Medigap policy because 
you lost certain kinds of health coverage. You should keep a copy of any letters, notices, and claim 
denials you get. Be sure to keep anything that has your name on it. Also, keep the postmarked 
envelope these papers come in. You may need to send a copy of some or all of these papers with your 
application for a Medigap policy to prove you lost coverage and have the right to these Medigap 
protections. The Medigap protections in this section are from Federal law. Many states provide more 
Medigap protections than Federal law. Call your State Health Insurance Assistance Program or State 
Insurance Department for more information (see pages 79-80). 

42 



Section 3: More Detailed Medigap Policy Information 



The Programs of All- 
inclusive Care for the 
Elderly (PACE) 
combines medical, 
social, and long-term 
care services for frail 
people. PACE is 
available only in states 
that choose to offer it 
under Medicaid. For 
more information about 
PACE, see page 61. 



Medigap Protections 

Situation #1 : Your Medicare + Choice Plan or PACE 
program coverage ends because the plan is leaving the 
Medicare program or stops giving care in your area. 



In this situation, your Medicare + Choice Plan or PACE program 
sends you a letter telling you that you will no longer be covered 
by the plan. You have the right to buy Medigap plan A, B, C, or F 
that is sold in your state by any insurance company. You can buy 
the policy at the best premium price available, with no review of 
your medical records even if you have health problems. 



You can apply for a Medigap policy as soon as you get the final 
notification letter from your plan. When you get this letter telling 
you that your plan is leaving the Medicare program or will no 
longer give care in your area, you may have three choices: 

1 . Switch to another Medicare + Choice Plan in your area. The 
final notification letter will tell you if there are other plans 
available in your area. In some cases, you may have to wait 
until the new plan you want to join is accepting new 
members. If you join a new Medicare + Choice Plan when 
your current plan coverage ends, you won't need (or be 
able to use) a Medigap policy. 

2. Leave your Medicare + Choice Plan or PACE program 
(disenroll) any time between the date you get your final 
notification letter and when your health coverage ends. 
Unless you join another Medicare + Choice Plan, you will 
automatically return to the Original Medicare Plan when you 
leave (disenroll from) your plan or PACE program. You have 
63 calendar days from the day you leave your plan or 
PACE program to apply for a Medigap policy. 

3. Stay in your plan or PACE program until the date your 
coverage ends. Unless you join another Medicare + Choice 
Plan, you will automatically return to the Original Medicare 
Plan when your coverage ends. You have 63 calendar days 
after your health coverage ends to apply for a Medigap 
policy. 



43 



Section 3: More Detailed Medigap Policy Information 
Medigap Protections (continued) 



Situation #1 : Your Medicare + Choice Plan or PACE program 
coverage ends because the plan is leaving the Medicare program or 
stops giving care in your area, (continued) 

Important: You will have additional rights under Situation #4 
(see page 45) or Situation #5 (see page 46) if: 

• This was the first time you were in a Medicare + Choice Plan, 

• You were in the plan less than one year before the plan left the 
Medicare program or stopped giving care in your area, and 

• You choose to return to the Original Medicare Plan and apply for a 
Medigap policy. 

If, instead, you immediately join another Medicare + Choice Plan, 
you can stay in that plan for up to one year and still have the rights 
described in Situations #4 and #5. 



Note: If you are 
covered by your 
spouse's employer 
group health plan 
(EGHP), and she/he 
retires, you will get 
guaranteed issue rights 
if your employer 
group health plan 
coverage is cancelled 
because you can no 
longer be covered 
under the terms of the 
plan. You will have 
guaranteed issue rights 
when your COBRA 
coverage is exhausted. 



Situation #2: Your employer group health plan coverage ends. 

You are in an employer group health plan that pays some or all of the 
costs not paid by Medicare, but plan coverage ends because the 
employer goes out of business or cancels your company coverage. 
You have the right to buy Medigap plan A, B, C, or F that is sold in 
your state by any insurance company. You can buy the policy at the 
best premium price available, with no review of your medical records 
even if you have health problems. 

You may get a letter or a notice from your employer, the health plan, 
or insurance company telling you your coverage has been or will be 
cancelled. You have 63 calendar days from the date your coverage ends 
or from the date on the letter or notice (whichever is later) to apply for 
a Medigap policy. In some cases, you won't get a notice, but you may 
get a claim denial. If this happens, this claim denial is the same as a 
letter telling you that your coverage has ended. Remember, keep a 
copy of the letter, notice, claim denial, and postmarked envelope. You 
may need these papers to prove you lost coverage. You will need to 
send a copy of the letter, notice, or claim denial with your application 
in order to buy a Medigap policy. 



44 



Section 3: More Detailed Medigap Policy Information 



Medigap Protections (continued) 

Situation #3: You have to end your health coverage because 
you move out of the plan's service area. 

If you have health coverage from a Medicare + Choice Plan, a 
Medicare SELECT policy, or you are in a PACE program, and 
you move out of the plan's service area, you will have to end 
your coverage. You have the right to buy Medigap plan A, B, C, 
or F that is sold in your state, or the state you are moving to, 
from any insurance company. You can buy the policy at the best 
premium price available, with no review of your medical 
records even if you have health problems. 

You must tell your current plan that you are moving and give 
them a date when you will end your coverage. .You can apply for 
a Medigap policy as early as 60 calendar days before the date 
your health coverage ends. You must apply for a Medigap policy 
no later than 63 calendar days after your health coverage ends. 

Situation #4: You joined a Medicare + Choice Plan or 
PACE program when you were first eligible for Medicare at 
age 65. Within the first year of joining, you decide you want 
to leave. 

You have the right to buy any Medigap policy that is sold in 
your state by any insurance company. You can buy the policy at 
the best premium price available, with no review of your 
medical records even if you have health problems. You must tell 
the plan that you want to leave (disenroll) and give them a date 
to end your coverage. You will have from 60 calendar days 
before your coverage ends until 63 calendar days after your 
coverage ends to apply for a new Medigap policy. 

Your rights under this situation may last for an extra 12 months 
if the plan you first joined leaves the Medicare program or 
stops giving care in your area before you have been in the plan 
for one year, AND you immediately join another Medicare + 
Choice Plan or PACE program. 



45 



Section 3: More Detailed Medigap Policy Information 



Medigap Protections (continued) 

Situation #5: You dropped a Medigap policy to join a Medicare + 
Choice Plan, Medicare SELECT policy, or PACE program for the 
first time and now you want to leave. You have been in the plan less 
than a year. 

You have the right to go back to your former Medigap policy, only if the 
same insurance company still sells it. You need to tell the Medicare + 
Choice Plan, Medicare SELECT, or PACE program or policy that you 
want to leave (disenroll) and give them a date to end your coverage. This 
date must be before you have been in the plan for a year. 

If your former Medigap policy isn't available, you have the right to buy 
Medigap plan A, B, C, or F that is sold in your state by any insurance 
company. You can buy the policy at the best premium price available, 
with no review of your medical records even if you have health 
problems. You will have from 60 calendar days before your coverage 
ends until 63 calendar days after your coverage ends to apply for a new 
Medigap policy. 

Your rights under this situation may last for an extra 12 months if the 
plan you first joined leaves the Medicare program or stops giving care 
in your area before you have been in the plan for one year, AND you 
immediately join another Medicare + Choice Plan or PACE program. 



Words in purple are 
defined on pages 82-85. 



Situation #6: Your Medigap insurance company goes bankrupt 
and you lose your coverage, or your Medigap policy coverage ends 
through no fault of your own. 

You have the right to buy Medigap plan A, B, C, or F that is sold in 
your state by any insurance company. You can buy the policy at the best 
premium price available, with no review of your medical records even 
if you have health problems. You will have 63 calendar days from the 
date your coverage ends to apply for a new Medigap policy. 



46 



Section 3: More Detailed Medigap Policy Information 



Medigap Protections (continued) 

Situation #7: You leave your plan because your Medicare + 
Choice Plan, Medicare SELECT, or Medigap insurance 
company has committed fraud. 

In this situation, you leave the health plan because it failed to 
meet its contract obligations to you. For example, the marketing 
materials were misleading, or quality standards weren't met. 
Generally, you must have filed a grievance with the health plan, 
Medicare, or the State Insurance Department and received a 
decision that the plan was at fault before you have this right. 

You have the right to buy Medigap plan A, B, C, or F that is 
sold in your state by any insurance company. You can buy the 
policy at the best premium price available, with no review of 
your medical records even if you have health problems. You 
must tell the plan that you want to leave (disenroll) and give 
them a date to end your coverage. You will have 63 calendar 
days from the date your coverage ends to apply for a new 
Medigap policy. 



Remember, some states provide more Medigap protections. 
Your state may let you choose from more Medigap policies or 
give you a longer time to apply for a Medigap policy when 
you lose your coverage. Call your State Health Insurance 
Assistance Program (see pages 79-80). 



If you live in Massachusetts, Minnesota, or Wisconsin, you 

have the same guaranteed issue rights (see pages 41-42) to buy 
a Medigap policy. If you have questions, call your State 
Insurance Department (see pages 79-80). 



47 



Section 3: More Detailed Medigap Policy Information 



Medigap Protections (continued) 

Special Note For People With Medicare Under Age 65 

If you are in a situation that gives you the right to buy a Medigap 
policy, you must be allowed to buy Medigap plan A, B, C, or F 
that is sold in your state to people under age 65. You can buy the 
policy at the best premium price available, with no review of 
your medical records. However, there is no Federal law that says 
insurance companies must sell Medigap policies to people under 
age 65. If an insurance company does sell these Medigap policies 
to anyone under age 65, they must sell one to you if you are in 
one of these situations (listed on pages 43-47). 

Special Note For People With End-Stage Renal Disease 
(ESRD) 

If you have ESRD and are in a Medicare + Choice Plan, and the 
plan leaves Medicare or no longer provides coverage in your area, 
you have a one-time right to join another Medicare + Choice Plan. 
You don't have to use your one-time right to join a new Medicare + 
Choice Plan immediately. If you change directly to the Original 
Medicare Plan after your plan leaves or stops providing coverage, 
you will still have a one-time right to join a Medicare + Choice Plan 
at a later date as long as you are in a managed care election period. 

Where To Get More Information About Medigap 
Protections 

• Call your State Health Insurance Assistance Program 
(see pages 79-80) to make sure that you qualify for these 
Medigap protections. They can also help you find 
the Medigap policy that is right for you. 

• Call your State Insurance Department (see pages 79-80) 
if you are denied Medigap coverage. 



48 



Section 3: More Detailed Medigap Policy Information 

Losing Medigap Coverage 

Can My Medigap Insurance Company Drop Me? 

In most cases, no. If you bought your Medigap policy after 
1990, the law says that your insurance company must let you 
renew your Medigap policy as long as you pay your premium. 
This means that the policy is guaranteed renewable. Your 
insurance company can drop you if you lie (for example, you 
commit fraud under the policy). Other than that, there is only 
one situation where you may lose a Medigap guaranteed 
renewable policy: if the insurance company goes bankrupt. If 
this happens, and state law doesn't make some other coverage 
available, you have the right to buy Medigap plan A, B, C, or F 
that is sold in your state (see Medigap Protections, Situation #6 
on page 46). 

Insurance companies in some states may refuse to renew 
Medigap policies that you bought before 1990. In order for an 
insurance company to refuse to renew one of these older 
Medigap policies, the company must get the state's approval 
and cancel all policies of this type that they sell in your state. If 
this happens, you have the right to buy Medigap plan A, B, C, 
or F that is sold in your state (see example below and Medigap 
Protections, Situation #6 on page 46). 



Words in purple are 
defined on pages 82-85. 



Example: 

In 1987, Mr. Jones bought a Medigap policy from Company 
X. The Medigap policy Mr. Jones bought is not guaranteed 
renewable because he bought it before 1990, and it didn't say 
it was guaranteed renewable. Company X won't renew Mr. 
Jones's policy because it is no longer being offered. The 
company is canceling all policies of this type in the state. 
Therefore, Mr. Jones has the right to buy Medigap plan A, B, 
C, or F that is sold in his state from any insurance company 
that offers them. 



49 



Section 3: More Detailed Medigap Policy Information 

Switching Medigap Policies 

Do I Have To Switch If I Have An Older Medigap 
Policy? 

No. If you have an older Medigap policy, you can keep it. You 
don't have to switch to one of the newer standardized Medigap 
plans. But, if you decide to switch your Medigap policy, you 
won't be able to go back to your older Medigap policy if you 
bought it before 1992 when standardized policies were first 
sold. 

What Should I Do Before Switching My Medigap 
Policy? 

Before switching policies, compare benefits and premiums. 
Some of the older Medigap policies may offer better coverage, 
especially for prescription drugs and long-term care. On the 
other hand, older Medigap policies may have bigger premium 
increases than newer standardized Medigap policies. 

Do I Have To Wait A Certain Length Of Time Before I 
Can Switch To A Different Medigap Policy? 

No, but the length of time you had your policy will affect how 
your new policy covers you for pre-existing conditions. Your 
new Medigap policy generally must cover all pre-existing 
conditions if you have had your current policy at least six 
months. 



Words in purple are 
defined on pages 82-85. 



Your new Medigap policy might not cover all pre-existing 
conditions if you've had your current Medigap policy for less 
than six months. However, the amount of time you've had your 
current Medigap policy must count towards the amount of time 
you must wait before your new policy covers your pre-existing 
condition. 



50 



Section 3: More Detailed Medigap Policy Information 



Do I Have To Wait A Certain Length Of Time Before I 
Can Switch To A Different Medigap Policy? (continued) 



If there is a benefit in the new Medigap policy that wasn't in 
your older policy, the company can make you wait up to six 
months before providing that benefit. 



51 



Section 3: More Detailed Medigap Policy Information 



How Your Bills Get Paid 

Does The Medigap Insurance Company Pay My 
Doctor Or Provider Directly? 

When you have a Medigap policy, the insurance company must 
pay your doctor or provider directly when: 

• Your doctor or provider has signed an agreement with 
Medicare to accept assignment of all Medicare claims 
for all their Medicare patients, and 

• You tell your doctor's office to put on the Medicare 
claim form that you want Medigap insurance benefits 
paid to the doctor or supplier. Your doctor should put your 
Medigap policy number and the company name on the 
Medicare claim form. You will need to sign the claim 
form or have your doctor keep your signature on record. 
Make sure this information is correct. 

When these conditions are met, the Medicare carrier will 
process the claim and send it to the Medigap insurance 
company. A Medicare carrier is a private company that has a 
contract with Medicare to pay Part B bills. The carrier will send 
you a Medicare Summary Notice. Your Medigap insurance 
company will pay your doctor or provider directly and then send 
you a notice. If you don't get this notice, you may ask your 
Medigap insurance company for it. 

In most cases, Medicare claims are sent directly to the 
insurance company, even if the doctor doesn't accept 
assignment on all claims. 

If Your Doctor Is Not Paid Directly 

If the Medigap insurance company doesn't pay your doctor 
directly when the above two conditions are met, you should report 
this to your State Insurance Department (see pages 79-80). For 
more information on Medigap claim filing by the carrier, call 
your Medicare carrier. Call 1-800-MEDICARE (1-800-633-4227) 
to get the telephone number of the Medicare carrier in your state. 
TTY users should call 1-877-486-2048. 



Words in purple are 
defined on pages 82-85. 



52 



Section 3: More Detailed Medigap Policy Information 



Private Contracts 

What Is A Private Contract? 

A private contract is an agreement between you and a doctor who 
has decided not to give services through the Medicare program. The 
private contract only applies to the services you get from the doctor 
who asked you to sign it. 

If I Sign A Private Contract With My Doctor, Will Medicare 
And My Medigap Policy Pay? 

Medicare and Medigap policies won't pay for the services you get 
from the doctor with whom you have a private contract. You can't be 
asked to sign a private contract in an emergency or urgent health 
situation. 

Note: You still have the right to see other Medicare doctors for 
services. 

If you sign a private contract with your doctor: 

• Medicare health plans won't pay any amount for the services you 
get from this doctor. 

• You will have to pay whatever this doctor or provider 

charges you for the services you get. Medicare's limiting charge 
won't apply. 

• No claim should be submitted to Medicare, and Medicare won't 
pay if one is submitted. 

• Your Medigap policy, if you have one, won't pay anything for this 
service. Call your Medigap insurance company before you get 
the service if you have any questions. 

• Many other insurance plans won't pay for the services either. 
Call your insurance company before you get the service if you 
have any questions. 

• Your doctor must tell you whether Medicare would pay for the 
service if you get it from another doctor who participates in 
Medicare. 



You may want to 
talk with 
someone in your 
State Health 
Insurance 
Assistance 
Program before 
signing a private 
contract (see 
pages 79-80). 



• Your doctor must tell you if he or she has been excluded 
from the Medicare program. 



53 



Section 3: More Detailed Medigap Policy Information 

Watch Out for Illegal Insurance Practices 

It is illegal for anyone to do the following: 

• Pressure you into buying a Medigap policy, or lie to 
you or mislead you to get you to switch from one 
company or policy to another. 

• Sell you a second Medigap policy when they know 
that you already have one, unless you tell the 
insurance company in writing that you plan to cancel 
your existing Medigap policy. 

• Sell you a Medigap policy if they know you have 
Medicaid, except in certain situations (see page 60). 

• Sell you a Medigap policy if they know you are 
enrolled in a Medicare + Choice Plan. 

• Claim that a Medigap policy is part of the Medicare 
program or any other Federal program. Remember, 
Medigap is private health insurance. 

• Sell you a Medigap policy that can't legally be sold in 
your state. Some Medigap insurance companies use 
direct mail advertising to sell policies. Check with 
your State Insurance Department to make sure that the 
Medigap plan you are interested in can be sold in your 
state. 

• Misuse the names, letters, symbols, or emblems of the 
U. S. Department of Health and Human Services 
(DHHS), Social Security Administration (SSA), 
Centers for Medicare & Medicaid Services (CMS), or 
any of their various programs like Medicare. 

If you believe that a Federal law has been broken, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. In most cases, however, your State Insurance 
Department can help you with insurance-related problems (see 
pages 79-80). 

54 



Section 3: More Detailed Medigap Policy Information 



Ways To Check If An Insurance Company Is Reliable 

Buying a Medigap policy is an important decision. You want to make 
sure that you are buying from a reliable insurance company. To help 
you find out if an insurance company is reliable, you can take the 
following actions: 

• Call the State Insurance Department in your state (see 

pages 79-80). Ask if they keep a record of complaints against 
insurance companies and whether these can be shared with you. 

• Go to your local public library. Your local public library can 
help you: 

• Get information on an insurance company's financial 
strength by independent rating services such as, Weiss 
Rating, Inc., A.M. Best, and Standard & Poors, and 

• Use the computer to look at information on the web. 

• Talk to someone you trust, like your insurance agent or a 
friend who has a Medigap policy. 

• Call the State Health Insurance Assistance Program 
in your state (see pages 79-80). These programs can 
give you free help with buying a Medigap policy. 



Words in purple are 
defined on pages 82-85. 



55 



Notes 



"I used this Guide to choose 
my Medigap policy." 




56 



Section 4: 
Other Ways To Pay 
Health Care Costs 




"This section has helpful information about other 
ways to pay for my health care." 



57 



Section 4: Other Ways To Pay Health Care Costs 



Other Kinds of Insurance and Ways To Pay Health 
Care Costs 

There are other kinds of health coverage, besides a Medigap policy, that 
may pay for some of your health care costs not covered by Medicare. They 
include the following: 

Medicare Savings Programs (help from your state) 59 

Medicaid 60 

The PACE Program (Programs of All-inclusive Care 

for the Elderly) 61 

Federally Qualified Health Centers (FQHCs) 62 

Home and Community-Based Service/Waiver Programs 

(HCBS) 62 

Employee or Retiree Coverage from an Employer or Union 63 

COBRA Coverage 63-64 

Long-Term Care Insurance 65 

Veterans' Benefits 65 

TRICARE for Life/Military Retiree Benefits 65-66 

Prescription Drug Assistance Programs 66 

Hospital Indemnity Insurance 66 

Specified Disease Insurance 66 

For more information about these kinds of health insurance and ways to pay 
health care costs, call 1-800-MEDICARE (1-800-633-4227). TTY users 
should call 1-877-486-2048. Ask for a free copy of the Health Care 
Coverage Directory for People with Medicare (CMS Pub. No. 02231) and 
Medicare and Other Health Benefits: Your Guide to Who Pays First (CMS 
Pub. No. 02179). You can also read or print a copy of these booklets at 
www.medicare.gov on the web. Select "Publications." 



58 



Section 4: Other Ways To Pay Health Care Costs 



Medicare Savings 
Programs may not be 
available in Guam, 
Puerto Rico, the 
Virgin Islands, the 
Northern Mariana 
Islands, and 
American Samoa. 



Medicare Savings Programs (Help From Your State) 

There are programs that help millions of people with Medicare save 
money each year. States have programs for people with limited 
income and resources that pay Medicare premiums. Some programs 
may also pay Medicare deductibles and coinsurance. 

You can apply for these programs if: 

• You have Medicare Part A, (If you are eligible for Medicare Part A 
but don't have it because you can't afford it, there is a program that 
may pay the Medicare Part A premium for you.) and 

• You are an individual with resources of $4,000 or less, or are a 
couple with resources of $6,000 or less. Resources include things 
like money in a checking or savings account, stocks, or bonds, and 

• You are an individual with a monthly income of less than $ 1 ,03 1 , * 
or a couple with a monthly income of less than $1,384.* 

* Income limits will change slightly in 2004. If you live in Alaska or 
Hawaii, income limits are slightly higher. 

Note: Individual states may have more generous income and/or 
resource requirements. 

Call your State Medical Assistance Office and ask for information on 
Medicare Savings Programs. If you need the telephone number, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. It's very important to call if you think you qualify for any 
of these Medicare Savings Programs, even if you aren't sure. 



Words in purple are 
defined on pages 82-85. 



State Children's Health Insurance Program (SCHIP) 

Free or low-cost health insurance is available now in your state for 
uninsured children under age 19. State Children's Health Insurance 
Programs help reach uninsured children whose families earn too 
much to qualify for Medicaid, but not enough to get private 
coverage. Information on your State's program is available through 
Insure Kids Now at 1-877-KIDS-NOW (1-877-543-7669). You can 
also look at www.insurekidsnow.gov on the web for more 
information. 



59 



J 



Section 4: Other Ways To Pay Health Care Costs 



Medicaid 



Medicaid is a joint federal and state program that helps pay medical costs for some 
people with limited incomes and resources. Most of your health care costs are covered 
if you have Medicare and you qualify for Medicaid. Medicaid programs vary from 
state to state. People with Medicaid may get coverage for nursing home care and 
outpatient prescription drugs that aren't covered by Medicare. For more information 
about Medicaid, call your State Medical Assistance Office. 

What should I do if I have a Medigap policy and then get Medicaid? 

You have the right to suspend the Medigap policy rather than drop it while you have 
Medicaid. However, in some cases, it may not be a good idea to suspend your Medigap 
policy. Call your State Medical Assistance Office to help you with this decision. 

If you do suspend your policy, while it is suspended, you don't pay premiums and it 
won't pay benefits. You can only suspend a Medigap policy for up to two years. At the 
end of the suspension, you can start it again without new medical underwriting or 
pre-existing condition waiting periods. Call your insurance company to find out how 
to suspend a policy. 

Can An Insurance Company Sell Me A Medigap Policy If I 
Already Have Medicaid? 

If you have Medicaid, an insurance company can sell you a Medigap 
policy only in certain situations (see chart below). 



If Medicaid pays your 
Medigap policy premium... 


The insurance company can 
legally sell you any Medigap 
policy 


If Medicaid pays your 
Medicare premiums, 
deductibles, or coinsurance... 


The insurance company can 
legally sell you Medigap plans 
H, I, or J 


If Medicaid only pays all or 
part of your Medicare Part B 
premium... 


The insurance company can 
legally sell you any Medigap 
policy 



In any other situation, it is illegal for an insurance company to 
sell you a Medigap policy if you have Medicaid. 



60 



■ 



Section 4: Other Ways To Pay Health Care Costs 



The PACE Program (Programs of All-inclusive Care 
for the Elderly) 

PACE combines medical, social, and long-term care 
services for frail people. PACE is available only in states 
that have chosen to offer it under Medicaid. To be eligible, 
you must meet the following criteria: 

• Be age 55 or older, 

• Live in the service area of a PACE program, 

• Be certified as eligible for nursing home care by the 
appropriate state agency, and 

• Be able to live safely in the community. 

If you are enrolled in a PACE program, you may have to 
pay a monthly premium depending on your Medicare or 
Medicaid eligibility. 

Services are given by a team of health care professionals. 
The services are usually given in a PACE center and 
include home and transportation services. Services include 
primary health services, physical and occupational therapy, 
social services, personal care and support services, 
nutrition counseling, and meals. The goal of PACE is to 
help people stay independent and living in their community 
as long as possible, while getting the high quality care they 
need. 

To find out if you are eligible, to find if there is a PACE site 
near you, or for more information, call your State Medical 
Assistance Office. If you need the telephone number, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 



Words in purple are 
defined on pages 82-85. 



For more information about PACE, you can also look at 
www.medicare.gov/Nursing/Alternatives/PACE.asp on the 
web for PACE locations and telephone numbers. 



61 



Section 4: Other Ways To Pay Health Care Costs 



Federally Qualified Health Centers (FQHCs) 

These are special health centers that can give you routine 
health care at a lower cost. FQHCs may include the following: 

• A community health center, 

• Tribal health clinic, 

• Migrant health service, and 

• Health center for the homeless. 

To find the FQHC nearest you, look at www.medicare.gov 
on the web. Select "Helpful Contacts." Or, call 
1-800-MEDICARE (1-800-633-4227). TTY users should 
call 1-877-486-2048. Ask for the telephone number of the 
Primary Care Association in your state. 

Home and Community-Based Service/Waiver 
Programs (HCBS) 

The HCBS programs offer different choices to some people 
with Medicaid. If you qualify, you will get care in your 
home and community so you can stay independent and 
close to your family and friends. HCBS programs help the 
elderly and disabled, mentally retarded, developmentally 
disabled, and certain other disabled adults. These programs 
give quality and low cost services. 

To get more information on HCBS programs, services, and 
eligibility, call your State Medical Assistance Office. If you 
need the telephone number, call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. 
You can also look at www.medicare.gov on the web. Select 
"Helpful Contacts." Select the state you want and select 
"Other Health Insurance Programs." 



62 



Section 4: Other Ways To Pay Health Care Costs 



Employee or Retiree Coverage from an Employer or Union 



Call the benefits administrator at your or your spouse's current or 
former employer or union. Ask if you have or can get health care 
coverage based on your or your spouse's past or current employment. 
Since this kind of health coverage isn't a Medigap policy, the rules 
that apply to Medigap policies don't apply. 

Note: When you have retiree coverage from an employer or union, 
they manage this coverage. They may change the benefits or 
premiums, and may also cancel the coverage if they choose. 



Caution: If you drop your employer or union group health 
coverage, you may not be able to get it back. For more 
information, call your employer's or union's benefits 
administrator. 



Important: If the employer or union health coverage ends, you may 
have the right to buy a Medigap policy. Your employer or union must 
tell you within 60 calendar days after the date your coverage ends. If 
they don't, your only notice that your coverage has ended could be a 
letter telling you that your claim for payment has been denied, or that 
a claim your doctor sent in for payment was denied (see Medigap 
Protections, Situation #2 on page 44). 

COBRA Coverage 

COBRA (The Consolidated Omnibus Budget Reconciliation Act of 
1985) is a law that lets employees and their dependents keep their 
group health coverage for a time after they leave their group health 
plan under certain conditions. This is called "continuation coverage." 



Words in purple are 
defined on pages 82-85. 



You may have this right if you lose your job, have your working hours 
reduced, or leave your job voluntarily. You may also have this right if 
you are covered under your spouse's plan and your spouse dies or you 
get divorced. 

COBRA generally lets you and your dependents keep the group coverage 
for 18 months (or up to 29 or 36 months in some cases). You may have to 
pay both your share and the employer's share of the premium. In some 
cases, you may also have to pay an administration fee. 



63 



Section 4: Other Ways To Pay Health Care Costs 



For more 
information about 
COBRA, look at 
www.dol.gov on the 
web. 



COBRA Coverage (continued) 

This law only applies to employers with 20 or more employees. Some 
state laws require employers with less than 20 employees to let you 
keep your group health coverage for a time. You can call your State 
Insurance Department (see pages 79-80) to find out if your state has 
this law or to get more information about group health coverage 
under COBRA. In most situations that give you COBRA rights, other 
than a divorce, you should get a'notice from your benefits 
administrator. If you don't get a notice, or if you get divorced, you 
should call your benefits administrator as soon as possible. 

Medicare and Continuation Coverage Under COBRA 

If you already have continuation coverage under COBRA when you 
enroll in Medicare, your COBRA coverage may end. This is because 
the employer has the option of canceling the continuation coverage at 
this time. The length of time your spouse may get coverage under 
COBRA may change when you enroll in Medicare. 

However, if you choose COBRA coverage after you enroll in 
Medicare, you can keep your continuation coverage. If you only have 
Medicare Part A when your group health plan coverage ends (based 
on current or active employment), you can enroll in Medicare Part 
B during a Special Enrollment Period without having to pay a higher 
Medicare Part B premium. This means you will have to sign up for 
Medicare Part B within eight months after your group health 
coverage ends or when the employment ends, whichever is first 
(see pages 7-8). If you don't sign up for Medicare Part B during 
the eight-month period, you will only be able to sign up during the 
General Enrollment Period (see page 7) and the cost of Medicare Part 
B may go up. Under COBRA, the employer group plan may require 
you to sign up for Medicare Part B. 

Remember, once you're age 65 or older and enrolled in Medicare 
Part B, the Medigap open enrollment period starts and can't be 
changed (see page 18). 

State law may give you the right to continue your coverage under 
COBRA beyond the point COBRA coverage would ordinarily end. 
Your rights will depend on what is allowed under the state law. For 
more information about your state's law, call your State Insurance 
Department (see pages 79-80). 



64 



Section 4: Other Ways To Pay Health Care Costs 



Long-Term Care Insurance 

This kind of insurance is sold by private insurance companies 
and usually covers medical care and non-medical care to help 
you with your personal care needs, such as bathing, dressing, 
using the bathroom, and eating. Generally, Medicare does not 
pay for long-term care. 

For more information about long-term care insurance, get a 
copy of A Shopper's Guide to Long-Term Care Insurance 
from either your State Insurance Department (see pages 
79-80) or the National Association of Insurance 
Commissioners, 2301 McGee Street, Suite 800, Kansas City, 
MO 64108-3600. 

For more information about the types of long-term care, get a 
free copy of Choosing Long-Term Care: A Guide for People 
with Medicare (CMS Pub. No. 02223). Look at 
www.medicare.gov on the web. Select "Publications." Or, you 
can call 1-800-MEDICARE (1-800-633-4227). TTY users 
should call 1-877-486-2048. 

Veterans 1 Benefits 

If you are a Veteran, call the U.S. Department of Veterans 
Affairs at 1-800-827-1000 for information about Veterans' 
benefits and services available in your area. 

TRICARE for Life/Military Retiree Benefits 

TRICARE for Life (TFL) provides expanded medical 
coverage for the following: Medicare-eligible uniformed 
services retirees, including retired National Guard members 
and reservists; Medicare-eligible family members and 
widow/widowers; and certain former spouses if they were 
eligible for TRICARE before age 65. You must have 
Medicare Part A and Part B to be eligible for TFL. 

If eligible, you get all Medicare-covered benefits under the 
Original Medicare Plan, plus all TFL-covered benefits. 



65 



Section 4: Other Ways To Pay Health Care Costs 






TRICARE for Life/Military Retiree Benefits (continued) 






If you use a Medicare provider, Medicare will be the first payer for all 
Medicare-covered services, and TFL will be the second payer. TFL will pay 
all Medicare copayments and deductibles and cover most of the costs of 
certain care not covered by Medicare. For more information on TFL, call 
1-888-DOD-LIFE (1-888-363-5433) or look at www.TRJCARE.osd.mil on 
the web. Call 1-800-538-9552 for other military retiree eligibility and benefit 
questions. 

Prescription Drug Assistance Programs 

There are programs that may offer you discounts or free medication. For more 
information, look at www.medicare.gov on the web. Select "Prescription Drug 
Assistance Programs." If you don't have a computer, your local senior center 
or library may be able to help you get this information. Or, call 
1-800-MEDICARE (1-800-633-4227) and ask for information about these 
programs. TTY users should call 1-877-486-2048. 

Note: If you are considering signing up for your state's Prescription Drug 
Assistance Program and you haven't yet purchased a Medigap policy, get your 
Medigap policy before you apply for prescription drug assistance because 
after you get the prescription drug assistance you may not be able to purchase 
a Medigap policy. 

Hospital Indemnity Insurance 

This kind of insurance pays a certain cash amount for each day you are in the 
hospital up to a certain number of days. It doesn't fill gaps in your Medicare 
coverage. Remember, Medicare and any Medigap policy you have will 
very likely cover costs from any hospital stay you have. Therefore, you may 
not need this insurance. 

Note: This kind of insurance isn't considered creditable coverage. 

Specified Disease Insurance 

This kind of insurance pays benefits for only a single disease, such as cancer, 
or for a group of diseases. It doesn't fill gaps in your Medicare coverage. 
Remember, Medicare and any Medigap policy you have will very likely 
cover costs from any specific disease you have. Therefore, you may not need 
this insurance. 

Note: This kind of insurance isn't considered creditable coverage. 



66 



Section 5: 
Coverage Charts 





W i A 



■V 



1 



"I used the Preventive Service chart to see if 
diabetes services were covered." 



67 



Section 5: Coverage Charts 



Medicare Part A and Part B Coverage Charts 

For: See page(s): 

Medicare Part A (Hospital Insurance) 69 

Medicare Part B (Medical Insurance) 70-72 

If you have general questions about Medicare Part A, call your 
Fiscal Intermediary. A Fiscal Intermediary is a private 
company that has a contract with Medicare to pay Medicare 
Part A and some Medicare Part B bills. 

If you have general questions about Medicare Part B, call your 
Medicare carrier. A Medicare carrier is a private company that 
has a contract with Medicare to pay Medicare Part B bills. 

If you have questions about durable medical equipment, 
including diabetic supplies, call your Durable Medical 
Equipment Regional Carrier (DMERC). A DMERC is a 
private company that has a contract with Medicare to pay bills 
for durable medical equipment. 

To get these telephone numbers, call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. You 
can also get these telephone numbers at www.medicare.gov on 
the web. Select "Helpful Contacts." 

Charts of Standardized Medigap Plans 

For: See page: 

Massachusetts 73 

Minnesota 74 

Wisconsin 75 

All other states 1 5 

For more information about these Medigap plans, call your 
State Insurance Department (see pages 79-80) or look at 
www.medicare.gov on the web. Select "Medicare Personal 
Plan Finder." 



68 



COVERED SERVICES IN MEDICARE PART A 


Medicare Part A (Hospital Insurance) 
Helps Pay For: 


What YOU Pay in 2003 * in the Original 
Medicare Plan 


Hospital Stays: Semiprivate room, meals, general 
nursing, and other hospital services and supplies. This 
includes inpatient care you get in critical access 
hospitals and mental health care. This doesn't include 
private duty nursing, or a television or telephone in your 
room. It also doesn't include a private room, unless 
medically necessary. Inpatient mental health care in a 
psychiatric facility is limited to 190 days in a lifetime. 


For each benefit period: 

• A total of $840 for a hospital stay of 1-60 days. 

• $210 per day for days 61-90 of a hospital stay. 

• $420 per day for days 91-150 of a hospital stay. 
(See Lifetime Reserve Days on page 83.) 

• All costs for each day beyond 150 days. 


Skilled Nursing Facility (SNF) Care: Semiprivate 
room, meals, skilled nursing and rehabilitative 
services, and other services and supplies (after a 
related 3-day hospital stay). 


For each benefit period: 

• Nothing for the first 20 days. 

• Up to $105 per day for days 21-100. 

• All costs beyond the 100th day in the benefit period. 

If you have questions about SNF care and conditions of 
coverage, call your Fiscal Intermediary. 


Home Health Care: Part-time skilled nursing care, 
physical therapy, occupational therapy, speech- 
language therapy, home health aide services, durable 
medical equipment (such as wheelchairs, hospital 
beds, oxygen, and walkers), medical supplies, and 
other services. 


• Nothing for home health care services. 

• 20% of the Medicare-approved amount for durable 
medical equipment. 

If you have questions about home health care and 
conditions of coverage, call your Regional Home Health 
Intermediary. 


Hospice Care: For people with a terminal illness, 
includes drugs for symptom control and pain relief, 
medical and support services from a Medicare- 
approved hospice, and other services not otherwise 

i covered by Medicare. Hospice care is usually given in 
your home. However, short-term hospital and 
inpatient respite care (care given to a hospice patient 

'< so that the usual caregiver can rest) are covered when 
needed. 


• A copayment of up to $5 for outpatient prescription drugs and 
5% of the Medicare-approved amount for inpatient respite 
care. The amount you pay for respite care can change each 
year. Room and board are generally not payable by Medicare 
except in certain cases. 

If you have questions about hospice care and conditions of 
coverage, call your Regional Home Health Intermediary. 


Blood: Pints of blood you get at a hospital or skilled 
nursing facility during a covered stay. 


• For the first three pints of blood, unless you or someone 
else donates blood to replace what you use. 



* New Medicare Part A and Part B amounts will be available by January 1, 2004. 

If you have general questions about Medicare Part A, call your Fiscal Intermediary. To get the telephone numbers for 
Fiscal Intermediaries or Regional Home Health Intermediaries, look at www.medicare.gov on the web. Select 
"Helpful Contacts." Or, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 69 



COVERED SERVICES IN MEDICARE PART B 



Medicare Part B (Medical Insurance) 
Helps Pay For: 


What YOU pay in 2003* in the 
Original Medicare Plan 


Medical and Other Services: Doctors' services (not 
routine physical exams), outpatient medical and 
surgical services and supplies, diagnostic tests, 
ambulatory surgery center facility fees for approved 
procedures, and durable medical equipment (such as 
wheelchairs, hospital beds, oxygen, and walkers). Also 
covers second surgical opinions, outpatient mental 
health care, and outpatient physical and occupational 
therapy, including speech-language therapy. 


• $100 deductible (once per calendar year). 

• 20% of the Medicare-approved amount after the 
deductible (if the doctor or provider accepts 
"assignment"). 

• 20% for all outpatient physical, occupational, and 
speech-language therapy services. 

• 50% for outpatient mental health care. 


Clinical Laboratory Service: Blood tests, 
urinalysis, and more. 


• Nothing for Medicare-approved services. 


Home Health Care: Part-time skilled nursing care, 
physical therapy, occupational therapy, speech-language 
therapy, home health aide services, medical social 
services, durable medical equipment (such as 
wheelchairs, hospital beds, oxygen, and walkers), 
medical supplies, and other services. 


• Nothing for Medicare-approved services. 

• 20% of the Medicare-approved amount for durable 
medical equipment. 

If you have questions about home health care and 
conditions of coverage call your Regional Home 
Health Intermediary. 


Outpatient Hospital Services: Hospital services 
and supplies received as an outpatient as part of a 
doctor's care. 


• A coinsurance or copayment amount, which may 
vary according to the service. 


Blood: Pints of blood you get as an outpatient or as 
part of a Part B covered service. 


• For the first three pints of blood, then 20% of the 
Medicare-approved amount for additional pints of 
blood (after the deductible), unless you or someone 
else donates blood to replace what you use. 



* New Medicare Part A and Part B amounts will be available by January 1 , 2004. 



Note: Actual amounts you must pay may be higher if the doctor or supplier doesn't accept assignment and you may 
have to pay the entire charge at the time of service. Medicare will then send you its share of the charge. If you 
have general questions about Medicare Part B, call your Medicare carrier. If you have questions about durable 
medical equipment, including diabetic supplies, call your Durable Medical Equipment Regional Carrier (DMERC). 
For their telephone numbers, look at www.medicare.gov on the web. Select "Helpful Contacts." Or, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 

70 





MEDICARE PART B PREVENTIVE SERVICES 




Medicare Part B Covered 


Who is 


What YOU pay in the 




Preventive Services 


covered... 


Original Medicare Plan... 




Bone Mass Measurements: 


Discuss with your doctor to 


20% of the Medicare-approved amount 




Once every 24 months for qualified 


determine if you are a qualified 


(or a copayment amount) after the 




individuals and more frequently if 


individual. 


yearly Part B deductible. 




medically necessary. 








Colorectal Cancer Screening: 


All people with Medicare 


Nothing for the fecal occult blood test. 




• Fecal Occult Blood Test - Once 


age 50 and older, except 


For all other tests, 20% of the 




every 12 months. 


there is no minimum age for 


Medicare-approved amount after the 




• Flexible Sigmoidoscopy - Once 


having a colonoscopy. 


yearly Part B deductible . 




every 48 months. 








• Colonoscopy - Once every 24 




For flexible sigmoidoscopy or 




months if you are at high risk for 




colonoscopy, you pay 25% of the 




colon cancer. If you are not at high 




Medicare-approved amount if the test is 




risk for colon cancer, once every 10 




done in a hospital outpatient 




years, but not within 48 months of a 




department. 




screening flexible sigmoidoscopy. 








• Barium Enema - Doctor can use this 








instead of flexible sigmoidoscopy or 








colonoscopy. 








Diabetes Services and Supplies: 


All people with Medicare 


20% of the Medicare-approved amount 




• Coverage for glucose monitors, test 


who have diabetes (insulin 


after the yearly Part B deductible. 




strips, and lancets. 


users and non-users). 






• Diabetes self-management training. 


Certain people with 
Medicare who are at risk for 
complications from diabetes. 
Your doctor or other health 
care provider must request 
these services. 






Mammogram Screening: 


All women with Medicare 


20% of the Medicare-approved amount 




• Once every 12 months. 


age 40 and older. You can 


with no Part B deductible. 




• Medicare also covers new digital 


also get one baseline 






technologies for mammogram 


mammogram between ages 






screenings. 


35 and 39. 










71 



MEDICARE PART B PREVENTIVE SERVICES (CONTINUED) 



Medicare Part B Covered 
Preventive Services 


Who is 
covered- 


What YOU pay in the 
Original Medicare Plan... 


Pap Test and Pelvic Examination 
(Includes a clinical breast exam): 

Once every 24 months. Once every 
12 months if you are at high risk for 
cervical or vaginal cancer, or if you 
are of childbearing age and have had 
an abnormal Pap test in the past 36 
months. 


All women with 
Medicare. 


Nothing for the Pap lab test. For Pap 
test collection, and pelvic and breast 
exams, 20% of the Medicare-approved 
amount (or a copayment amount) with 
no Part B deductible . 


Prostate Cancer Screening: 

• Digital Rectal Examination - Once 
every 12 months. 

• Prostate Specific Antigen (PSA) 
Test - Once every 12 months. 


All men with Medicare age 
50 and older (coverage 
begins the day after your 
50th birthday). 


Generally, 20% of the Medicare- 
approved amount for the digital rectal 
exam after the yearly Part B deductible. 
No coinsurance and no Part B 
deductible for the PSA Test. 


Shots (vaccinations): 

• Flu Shot* - Once a year in the fall 
or winter. 

• Pneumococcal Pneumonia Shot - 
One shot may be all you will ever 
need. Ask your doctor. 

• Hepatitis B Shot 


All people with Medicare. 
All people with Medicare. 

Certain people with 
Medicare at medium to high 
risk for Hepatitis B. 


Nothing for flu and pneumococcal 
pneumonia shots if the health care 
provider accepts assignment. 

For Hepatitis B shots, 20% of the 
Medicare-approved amount (or a 
copayment amount) after the yearly 
Part B deductible. 


Glaucoma Screening: 

Once every 12 months. Must be done 
or supervised by an eye doctor who is 
legally allowed to do this service in 
your state. 


People with Medicare who 
are at high risk for 
glaucoma, including people 
with diabetes, a family 
history of glaucoma, or 
African- Americans who are 
age 50 and older. 


20% of the Medicare-approved amount 
after the yearly Part B deductible. 



*The flu is a serious illness that can lead to pneumonia. It can be dangerous for people age 50 and older. 
You need a flu shot each year because flu viruses are always changing. The shot is updated each year for 
the most current flu viruses. Also, the flu shot only helps protect you from the flu for about one year. 



72 



Section 5: Coverage Charts 



Chart Of Standardized Medigap Plans In Massachusetts 

Basic Benefits included in all plans: 

• Inpatient Hospital Care: Covers the Medicare Part A coinsurance and the cost of 365 extra 
days of hospital care during your lifetime after Medicare coverage ends. 

• Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of the Medicare- 
approved payment amount). 

• Blood: Covers the first three pints of blood each year. 



Medigap Benefits 


Core 
Plan 


Supplement 1 
Plan 


Supplement 2 
Plan 


Basic Benefits 


/ 


/ 


/ 


Medicare Part A: Inpatient 
Hospital Deductible 




/ 


/ 


Medicare Part A: Skilled-Nursing 
Facility Coinsurance 




/ 


/ 


Medicare Part B: Deductible 




/ 


/ 


Foreign Travel 
Emergency 




/ 


/ 


Inpatient Days in Mental 
Health Hospitals 


60 days per 
calendar year 


120 days per 
benefit year 


120 days per 
benefit year 


Prescription Drugs 

($35 deductible each calendar 
quarter, then 100% coverage for 
generic drugs and 80% coverage for 
brand name drugs) 






/ 


State-Mandated Benefits 

(Annual Pap tests and 
mammograms. Check your plan 
for other state-mandated benefits.) 


/ 


/ 


/ 



For more information on these policies, call your State Insurance Department (see pages 
79-80) or look at www.medicare.gov on the web. Select "Medicare Personal Plan Finder." 

Note: The checkmarks in this chart mean the benefit is covered under that plan. 



73 



Section 5: Coverage Charts 



Chart Of Standardized Medigap Plans In Minnesota 

Basic Benefits included in all plans: 

• Inpatient Hospital Care: Covers the Medicare Part A coinsurance. 

• Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of the 
Medicare-approved payment amount). 



Blood: Covers the first three pints of blood each year. 



Medigap Benefits 


Basic Plan 


Extended Basic 
Plan 


Basic Benefits 


/ 


/ 


Medicare Part A: Inpatient 
Hospital Deductible 




/ 


Medicare Part A: Skilled- 
Nursing Facility Coinsurance 


/ 


/ 


Medicare Part B: Deductible 




/ 


Foreign Travel 
Emergency 


80% 


80%* 


Outpatient Mental Health 


50% 


50% 


Usual and Customary Fees 




80%* 


Preventive Care 


/ 


/ 


Prescription Drugs 




80% 


At-home Recovery 




/ 


Physical Therapy 


20% 


20% 


Coverage while in a 
Foreign Country 




80%* 


State-Mandated Benefits 
(Diabetic equipment 
and supplies, routine cancer 
screening, reconstructive surgery, 
and immunizations.) 


/ 


/ 



Optional Riders 



• Medicare Part A: 
Inpatient Hospital 
Deductible 

• Medicare Part B: 
Deductible 

• Usual and Customary 
Fees 

• Preventive Care 

• Prescription Drugs 

• At-home recovery 

Insurance companies are 
allowed to offer six 
additional riders that can 
be added to a Basic plan. 
You may choose any one 
or all of the riders to 
design a Medigap plan that 
meets your needs. 



: The policy pays 100% after you spend $1000 of out-of-pocket expenses for a calendar year. 
74 Note: The checkmarks in this chart mean the benefit is covered under that plan. 



Section 5: Coverage Charts 



Chart Of Standardized Medigap Plans In Wisconsin 

Basic Benefits included in all plans: 

• Inpatient Hospital Care: Covers the Medicare Part A coinsurance. 

• Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of 
the Medicare-approved payment amount). 

• Blood: Covers the first three pints of blood each year. 



Medigap Benefits 


Basic Plan 


Basic Benefits 


/ 


Medicare Part A: 
Skilled-Nursing Facility 
Coinsurance 


/ 


Inpatient Mental 
Health Coverage 


175 days per lifetime in 
addition to Medicare 


Home Health Care 


40 visits in addition to 
those paid by Medicare 


Medicare Part B: 
Coinsurance 


/ 


Outpatient Mental Health 


/ 


Prescription Drugs 
(after a deductible of 
$6,250, pays 80%) 


/ 



Optional Riders 



• Medicare Part A Deductible 

• Additional Home Health Care 
(365 visits including those 
paid by Medicare) 

• Medicare Part B Deductible 

• Medicare Part B Excess 
Charges 

• Outpatient Prescription Drugs 

• Foreign Travel 

Insurance companies are 
allowed to offer additional 
riders to a Medigap plan. 



Wisconsin also has many other state mandated benefits under the Medigap Basic 
Plan. For more information, call your State Insurance Department (see pages 79-80) 
or look at www.medicare.gov on the web. Select "Medicare Personal Plan Finder." 

Note: The checkmarks in this chart mean the benefit is covered under that plan. 



75 



Notes 




"It is nice to know there is 
somewhere to go to get more 
information." 



76 



Section 6: 
For More Information 




"You can call 
1-800-MEDICARE 
(1-800-633-4227) 24 hours a 
day, including weekends. 
TTY users can call 
1-877-486-2048." 




"We visit www.medicare.gov for the latest Medicare information." 



77 



Section 6: For More Information 



In this section, you will find telephone numbers to call for help with your 
questions. These telephone numbers were correct at the time of printing. 
Telephone numbers sometimes change. You can find the most up-to-date 
telephone numbers by looking at www.medicare.gov on the web. Select 
"Helpful Contacts." Or, call 1-800-MEDICARE (1-800-633-4227). 
TTY users should call 1-877-486-2048. 

Where To Get More Information 

• Call your State Health Insurance Assistance Program for help with: 

• buying a Medigap policy, or long-term care insurance 

• dealing with payment denials or appeals 

• Medicare rights and protections 

• complaints about your care or treatment 

• choosing a Medicare health plan 

• questions about Medicare bills 

• Call your State Insurance Department if you have questions about 
the Medigap policies sold in your area and any insurance related 
problems. 



78 



Section 6: For More Information 



State Name 


State Health Insurance Assistance 
Program 


State Insurance 
Department 


Alabama 


(800) 243-5463 


(334) 269-3550 


Alaska 


(907) 269-3680 


(907) 269-7900 


/American Samoa 


(888) 875-9229 


(684)633-4116 


Arizona 


(800) 432-4040 


(602)912-8444 


Arkansas 


(800) 224-6330 


(800) 224-6330 


California 


(800) 434-0222 


(213)897-8921 


Colorado 


(888) 696-7213 


(303) 894-7499 


Connecticut 


(860) 424-5245 


(860) 297-3800 


Delaware 


(302) 739-6266 


(302)739-4251 


Florida 


(800) 963-5337 


(850)413-3100 


Georgia 


(800) 669-8387 


(800) 656-2298 


Guam 


(888) 875-9229 


(671)475-1817 


Hawaii 


(888) 875-9229 


(808) 586-2790 


Idaho 


(208) 334-4350 


(208) 334-4250 


Illinois 


(217)785-9021 


(312)814-2427 


Indiana 


(317)232-5299 


(317)232-2395 


Iowa 


(800)351-4664 


(800)351-4664 


Kansas 


(316)337-7386 


(785)296-3071 


Kentucky 


(877) 293-7447 


(800) 595-6053 


Louisiana 


(225) 342-5301 


(225) 342-5900 


Maine 


(207) 623-1797 


(207) 624-8475 


Maryland 


(410)767-1100 


(800)492-6116 


Massachusetts 


(800) 243-4636 


(617)521-7794 


Michigan 


(800) 803-7174 


(877) 999-6442 


Minnesota 


(800) 333-2433 


(651)296-4026 


Mississippi 


(800) 948-3090 


(601) 359-3569 


Missouri 


(800) 390-3330 


(800) 726-7390 


Montana 


(406) 444-4077 


(406) 444-2040 


Nebraska 


(800)234-7119 


(800)234-7119 



Section 6: For More Information 



State Name 


State Health Insurance Assistance 
Program 


State Insurance 
Department 


Nevada 


(800) 307-4444 


(775) 687-4270 


New Hampshire 


(603) 225-9000 


(800) 852-3416 


New Jersey 


(609) 943-3437 


(609) 292-5360 


New Mexico 


(505) 827-7640 


(505) 827-4601 


New York 


(800)333-4114 


(212)480-6400 


North Carolina 


(919)733-0111 


(919)733-0111 


North Dakota 


(800) 247-0560 


(800) 247-0560 


Northern Mariana 
Islands 


(888) 875-9229 


(670) 664-3017 


Ohio 


(800)686-1578 


(800)686-1526 


Oklahoma 


(405) 521-6628 


(405) 521-2828 


Oregon 


(503) 947-7984 


(503) 947-7984 


Pennsylvania 


(800) 783-7067 


(717)787-2317 


Puerto Rico 


(877) 725-4300 


(787) 722-8686 


Rhode Island 


(401) 222-2880 


(401)222-2223 


South Carolina 


(800) 868-9095 


(803) 737-6160 


South Dakota 


(605) 773-3656 


(605) 773-3563 


Tennessee 


(877) 801-0044 


(800)525-2816 


Texas 


(800) 252-9240 


(800) 252-3439 


Utah 


(801)538-3910 


(801) 538-3077 


Vermont 


(802)748-5182 


(802) 828-2900 


Virgin Islands 


(340) 772-7368 


(340) 774-7166 


Virginia 


(800) 552-3402 


(804)371-9691 


Washington 


(800) 397-4422 


(800) 397-4422 


Washington D.C. 


(202) 739-0668 


(202) 727-8000 


West Virginia 


(877) 987-4463 


(304) 558-3386 


Wisconsin 


(800)242-1060 


(608) 266-3585 


Wyoming 


(800) 856-4398 


(307) 777-7401 



80 



Section 7: 
Words To Know 




f mgtt^^i * Aft ^H 








"I used this section to look up words I didn't know." 





81 



Section 7: Words To Know 



Assignment: In the Original Medicare Plan, this 
means a doctor agrees to accept the Medicare- 
approved amount as full payment. If you are in the 
Original Medicare Plan, it can save you money if 
your doctor accepts assignment. You still pay your 
share of the cost of the doctor's visit. 



Durable Medical Equipment (DME): Medical 
equipment that is ordered by a doctor for use in 
the home. These items must be reusable, such as 
walkers, wheelchairs, or hospital beds. DME is 
paid for under both Medicare Part B and Part A 
for home health services. 



Benefit Period: The way that Medicare measures 
your use of hospital and skilled nursing facility 
services. A benefit period begins the day you go to a 
hospital or Skilled Nursing Facility (SNF). The 
benefit period ends when you haven't received any 
hospital or skilled care (in a SNF) for 60 days in a 
row. If you go into the hospital after one benefit 
period has ended, a new benefit period begins. You 
must pay the inpatient hospital deductible for each 
benefit period. There is no limit to the number of 
benefit periods you can have. 

Coinsurance: The percent of the Medicare- 
approved amount that you have to pay for items and 
services under Part A and/or Part B. In the Original 
Medicare Plan, the coinsurance payment is a 
percentage of the approved amount for the service 
(like 20%). 

Copayment: In some Medicare health plans, the 
amount that you pay for each medical service, 
like a doctor's visit. A copayment is usually a set 
amount you pay for a service. For example, this 
could be $5 or $10 for a doctor's visit. 
Copayments are also used for some hospital 
outpatient services in the Original Medicare Plan. 

Deductible: The amount you must pay for 
Medicare covered services, before Medicare 
begins to pay, either for each benefit period for 
Part A, or each year for Part B. These amounts 
can change every year. 



Durable Medical Equipment Regional Carrier 

'(DMERC): A private company that contracts 
with Medicare to pay bills for durable medical 
equipment. 

End-Stage Renal Disease (ESRD)*: Kidney 
failure that is severe enough to need lifetime 
dialysis or a kidney transplant. 

Excess Charges: Any amount that the doctor or 
supplier charges you that is more than what 
Medicare will pay for (see "Medicare-Approved 
Amount"). 

Fiscal Intermediary: A private company that 
has a contract with Medicare to pay Part A and 
some Part B bills. (Also called "Intermediary.") 

Guaranteed Issue Rights (also called 
"Medigap Protections"): Rights you have in 
certain situations when insurance companies are 
required by law to sell or offer you a Medigap 
policy. In these situations, an insurance company 
can't deny you insurance coverage or place 
conditions on a policy, must cover you for all 
pre-existing conditions, and can't charge you 
more for a policy because of past or present 
health problems. 



82 



* This definition in whole or in part was used with permission from Walter Feldesman, Esq., 
"Dictionary of Eldercare Terminology 2000." 



G 



Section 7: Words To Know 



uaranteed Renewable: A right you have that 
requires your insurance company to automatically 
renew or continue your Medigap policy, unless 
you commit fraud or don't pay your premiums. 

I Home Health Care: Skilled nursing care and 
certain other health care you get in your home 
for the treatment of an illness or injury. 

Hospice Care: A special way of caring for 
people who are terminally ill, and for their 
family. This care includes physical care and 
counseling. Hospice care is covered under 
Medicare Part A (Hospital Insurance). 

Lifetime Reserve Days: Sixty days that 
Medicare will pay for when you are in a hospital 
for more than 90 days. These 60 reserve days can 
be used only once during your lifetime. For each 
lifetime reserve day, Medicare pays all covered 
costs except for a daily coinsurance ($420 in 
2003). 

i Limiting Charge: The highest amount of money 
you can be charged for a covered service by 
doctors and other health care providers who don't 
accept assignment. The limit is 15% over 
Medicare's approved amount. The limiting charge 
only applies to certain services and does not 
apply to supplies or equipment. 

Long-Term Care: A variety of services that help 
people with health or personal needs and 
activities of daily living over a long period of 
time. Long-term care can be provided at home; in 
the community; or in various types of facilities, 
including nursing homes and assisted living 
facilities. Most long-term care is custodial care. 
Medicare doesn't pay for this type of care. 



Medicaid: A joint federal and state program that 
helps with medical costs for some people with 
low incomes and limited resources. Medicaid 
programs vary from state to state, but most health 
care costs are covered if you qualify for both 
Medicare and Medicaid. 

Medical Underwriting: The process that an 
insurance company uses to decide whether or not 
to take your application for insurance, whether or 
not to add a waiting period for pre-existing 
conditions (if your state law allows it), and how 
much to charge you for that insurance. 

Medically Necessary: Services or supplies that: 

• are proper and needed for the diagnosis or 
treatment of your medical condition, 

• are provided for the diagnosis, direct care, 
and treatment of your medical condition, 

• meet the standards of good medical 
practice in the local area, and 

• are not mainly for the convenience of you 
or your doctor. 

Medicare + Choice Plan: A Medicare program 
that gives you more choices among health plans. 
Everyone who has Medicare Parts A and B is 
eligible, except those who have End-Stage Renal 
Disease. 

Medicare- Approved Amount: The fee Medicare 
sets as reasonable for a covered medical service. 
This is the amount a doctor or supplier is paid by 
you and Medicare for a service or supply. It may 
be less than the actual amount charged by a 
doctor or supplier. The approved amount is 
sometimes called the "Approved Charge." 



83 



Section 7: Words To Know 



- 



Medicare Carrier: A private company that 
contracts with Medicare to pay Part B bills. 

Medicare Managed Care Plan: These are health 
care choices (like HMOs) in some areas of the 
country. In most plans, you can only go to 
doctors, specialists, or hospitals on the plan's list. 
Plans must cover all Medicare Part A and Part B 
health care. Some plans cover extras, like 
prescription drugs. Your costs may be lower than 
in the Original Medicare Plan. 

Medicare Private Fee-for-Service Plan: A 

private insurance plan that accepts people with 
Medicare. You may go to any Medicare-approved 
doctor or hospital that accepts the plan's 
payment. The insurance plan, rather than the 
Medicare program, decides how much it will pay 
and what you pay for the services you get. You 
may pay more for Medicare-covered benefits. 
You may have extra benefits the Original 
Medicare Plan doesn't cover. 

Medicare SELECT: A type of Medigap policy 
that may require you to use hospitals and, in 
some cases, doctors within its network to be 
eligible for full benefits. 

Medigap Policy: A Medicare supplement 
insurance policy sold by private insurance 
companies to fill "gaps" in Original Medicare 
Plan coverage. Except in Massachusetts, 
Minnesota, and Wisconsin, there are ten 
standardized plans labeled Plan A through Plan J. 
Medigap policies only work with the Original 
Medicare Plan. 



Open Enrollment Period: A one-time-only six 
month period when you can buy any Medigap 
policy you want that is sold in your state. It starts 
when you sign up for Medicare Part B and you 
are age 65 or older. During this period, you 
cannot be denied coverage or charged more due 
to past or present health problems. 

Original Medicare Plan: A fee-for-service 
health plan that lets you go to any doctor, 
hospital, or other health care provider who 
accepts Medicare. You must pay any applicable 
deductible. Medicare then pays its share of the 
Medicare-approved amount, and you pay your 
share (coinsurance). The Original Medicare Plan 
has two parts: Part A (Hospital Insurance) and 
Part B (Medical Insurance). 

Pre-existing Condition: A health problem you 
had before the date that a new insurance policy 
starts. 



Premium: The periodic payment to Medicare, an 
insurance company, or a health care plan for 
health care coverage. 

Programs of All-inclusive Care for the Elderly 
(PACE): PACE combines medical, social, and 
long-term care services for frail people. PACE is 
available only in states that have chosen to offer 
it under Medicaid. To be eligible, you must: 

• Be 55 years old or older, 

• Live in the service area of the PACE program, 

• Be certified as eligible for nursing home care 
by the appropriate state agency, and 

• Be able to live safely in the community. 
The goal of PACE is to help people stay 
independent and living in their community as 
long as possible, while getting high quality care 
they need. 



84 



Section 7: Words To Know 



Skilled Nursing Care*: A level of care that must 
be given or supervised by Registered Nurses. All 
of your needs are taken care of with this type of 
service. Examples of skilled care are: getting 
intravenous injections, tube feeding, oxygen to 
help you breathe, and changing sterile dressings 
on a wound. Any service that could be safely 
done by an average non-medical person (or one's 
self) without the supervision of a Registered 
Nurse is not considered skilled care. 



j Skilled Nursing Facility: A nursing facility with 
jthe staff and equipment to give skilled nursing 
care and/or skilled rehabilitation services and 
other related health services. 

State Health Insurance Assistance Program: A 

state program that gets money from the Federal 
Government to give free health insurance 
counseling and assistance to people with 
Medicare. 

State Insurance Department: A state agency 
that regulates insurance and can provide 
information about Medigap policies and any 
insurance-related problem. 

State Medical Assistance Office: A state agency 
that is in charge of the State's Medicaid program 
and can provide information about programs to 
help pay medical bills for people with low 
incomes. Also provides help with prescription 
drug coverage. 



* This definition in whole or in part was used with permission from Walter Feldesman, Esq., 
"Dictionary of Eldercare Terminology 2000." 



85 



Notes 






"I bought my Medigap 
policy during my 
Medigap open enrollment 
period." 




86 



Section 8 
Index 




This section is an alphabetical list of what is in this Guide. 



87 



Section 8: Index 



Assignment 12, 13,52,82 

At-home Recovery 15, 22, 25 

Attained-Age-Rated Policies 34-35 

B 

Basic Benefits 14, 15,23 

Basic Drug Benefit 4, 25 

Benefit Period 69, 82 

Blood 13, 14,23,69,70 



H 

High Deductible Option 15, 17 

Home and Community-Based 

Service/Waiver Programs (HCBS) 58, 62 

Home Health Care 5, 69, 70, 83 

Hospice Care 5, 69, 83 

Hospital Indemnity Insurance 58, 66 

I 
Issue-Age-Rated Policies 34 



Coinsurance 13, 14, 23, 70, 82 

Consolidated Omnibus Budget Reconciliation 

Act of 1985 (COBRA) 58, 63, 64 

Copayment 13, 14, 23, 69, 70, 82 

Cost 16, 17,34,35 

Creditable Coverage 18, 36, 37 

D 

Deductible 15, 17, 22-24, 82 

Disability 8,38-40 

Durable Medical 

Equipment 69, 70, 82 

Durable Medical 

Equipment Regional Carrier 68, 70, 82 

E 

Employee Coverage 58, 63 

Employer Group Health Plan ..7, 1 1, 20, 37, 44 
End- Stage Renal 

Disease (ESRD) 11, 18, 38-40, 82 

Excess Charges 13, 15, 22, 24, 82 

F 

Federally Qualified Health Centers 58, 62 

Finding Reliable Insurance Companies 55 

Fiscal Intermediary 68,69, 82 

Foreign Travel Emergency 15, 17, 22, 24 

G 

General Enrollment Period (Part B) 7 

Group Health Coverage 7 

Guaranteed Issue Rights 36, 41, 82 

Guaranteed Renewable 10, 49, 83 



Lifetime Reserve Days 69, 83 

Limiting Charge 53, 83 

Long-Term Care Insurance 58, 65 

M 

Medicaid 10, 11, 58, 60, 83 

Medical Underwriting 16, 17, 83 

Medically Necessary 5, 83 

Medicare + Choice 4, 10, 11, 43-48, 83 

Medicare Card 5 

Medicare Carrier 52, 68, 84 

Medicare Managed Care Plan 4, 84 

Medicare Part A (Hospital Insurance) 4, 5, 69 

Medicare Part B (Medical 

Insurance) 4-8, 70-72 

Medicare Personal Plan Finder ....27, 40, 73, 75 

Medicare Private Fee-for-Service Plan 4, 84 

Medicare Savings Programs 58, 59 

Medicare SELECT 11, 84 

Medicare Supplement Insurance.. (see Medigap) 
Medigap 

Cost 16, 17, 34, 35 

Steps To Buying 20-31 

Under age 65 38-40 

What It Is 10, 84 

What's Covered 14 

What's Not Covered 14 

When To Buy 18, 19 

Why You Might Need It 12, 13 



88 

i) U. S. G. P. O. 2003-570-924 



Section 8: Index 



M (continued) 

Medigap Benefits Chart 15 

For Massachusetts 73 

For Minnesota 74 

For Wisconsin 75 

Medigap Protections 41-47 

N 

No-Age-Rated Policies 34 

o 

Open Enrollment 

Period (Medigap) ..7, 18-20, 28, 36, 38, 39, 84 

Original Medicare Plan 4, 10-12, 84 

Other Ways to Pay Health Care Costs 58-66 

Out-of-Pocket Costs 12 

P 
PACE (Programs of All-inclusive Care 

for the Elderly) 43-46, 58, 61, 84 

Part A (Hospital Insurance) 4, 5, 69 

Part B (Medical Insurance) 4-8, 18-20, 70-72 

Pre-existing Condition 18, 36, 84 

Premium 5, 6, 10, 16, 34, 35, 84 

Prescription Drug Assistance 

Programs 58, 66 

Prescription Drugs 4, 14, 15, 17,22,25 

Preventive Care 15, 22, 25, 71-72 

Pricing Policies 16, 17,34,35 

Private Contract 53 

R 

Railroad Retirement Board 6, 7 

Reliability 27, 55 

Retiree Coverage 58, 63 



Skilled Nursing Care 5, 15, 22, 24, 69, 85 

Skilled Nursing Facility 

Care 5, 22, 24, 69, 85 

Social Security Administration 6-8 

Special Enrollment Period (Part B) 7, 8 

Specified Disease Insurance 58, 66 

Standardized Medigap Plans 10, 14, 15 

For Massachusetts 73 

For Minnesota 74 

For Wisconsin 75 

State Children's Health Insurance Program. ...59 
State Health Insurance Assistance 

Program 26, 27, 39, 42, 48, 55, 79, 80, 85 

State Insurance 

Department 27, 42, 48, 54, 55, 79, 80, 85 

State Medical Assistance 

Office 59-61, 85 

T 
TRICARE For Life/Military 

Retiree Benefits 37, 58, 65, 66 

u 

Union Coverage 7, 11, 20, 58, 63 



Veterans' Benefits 58, 65 

w 

Waiting Period 36-38 

www.medicare.gov 4, 27, 40, 68-71, 73, 75 



89 



CHS LIBRARY 



US. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services "3" ""ab'^s "" d ddl' i'd trj 7 

7500 Security Boulevard 
Baltimore, Maryland 21244-1850 



Official Business 

Penalty for Private Use, $300 

Publication No. CMS - 021 10 
Revised March 2003 




To get the 2003 Guide To Health Insurance For People With 
Medicare: Choosing a Medigap Policy on Audiotape (English 
and Spanish), in Braille, Large Print (English), or Spanish, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 

^Necesita usted una copia de esta guia en Espanol? Tambien 
esta disponible en audiocassette. Llame gratis al 
1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY 
deberan llamar al 1-877-486-2048.